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PELVIC   INFLAMMATION 
IN  WOMEN 


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PELVIC  INFLAMMATION 
IN  WOMEN 


BY 


JOHN  OSBORN  POLAK,  M.Sc,  M.D.,  F.A.C.S. 

PROFESSOE  OF  OBSTETRICS  AND  GYNECOLOGY,  LONG   ISLAND    COLLEGE    HOSPITAL; 
OBSTETRICIAN     AND    GYNECOLOGIST,    LONG    ISLAND     COLLEGE     HOSPITAL; 
GYNECOLOGIST,    JEWISH    HOSPITAL;     CONSULTING    GYNECOLOGIST, 
BUSHWICK,     CONEY     ISLAND,     DEACONESS,     PEOPLE's     AND 
WILLIAMSBURG    HOSPITALS;    CONSULTING    OBSTETRI- 
CIAN,    METHODIST     EPISCOPAL     HOSPITAL 


GYNECOLOGICAL  AND  OBSTETRICAL  MONOGRAPHS 


WITH  TWO   COLORED   PLATES    AND 
EIGHTY-EIGHT   ILLUSTRATIONS 


D.  APPLETON  AND  COMPANY 

NEW  YORK  ■  LONDON 

1921 


COPYRIGHT,    1921,   BY 

D.  APPLETON  AND  COMPANY 


PRINTED   IN  TH1!:   ^^^TED   STATES   OF   AJTERICA 


PREFACE 

This  monograph  is  presented  to  the  medical  profession  in  the  hope 
that  it  may  serve  a  purpose,  i.e.,  to  awaken  in  both  the  practitioner  and 
the  speciaHst  a  keener  appreciation  of  the  importance  of  that  large  group 
of  diseases  peculiar  to  women  which  result  from  septic  gonorrhoeal  and 
tuberculous  infections. 

Nowhere  in  the  English  or  American  literature  is  the  subject  pre- 
sented in  its  entirety,  and  while  the  author  does  not  presume  to  present 
a  resume  of  all  the  literature  on  the  subject,  he  has  attempted  to  de- 
scribe concisely  and  consecutively  the  common  inflammatory  lesions  af- 
fecting the  genital  organs  in  women. 

While  some  of  the  statements  may  appear  dogmatic  and  have  been 
repeated  several  times  in  the  text,  many  years  of  clinical  teaching  has 
convinced  the  author  that  there  are  certain  positive  truths  in  medicine 
which  cannot  be  taught  except  by  positiveness  and  repetition. 

In  this  work  the  effort  has  been  made  to  give  the  reader  the  accepted 
pathology,  a  definite  clinical  picture  and  a  description  of  the  treatment 
which  has  best  served  the  author  in  his  special  practice. 

I  take  this  opportunity  to  express  my  appreciation  and  thanks  to 
my  associates,  Drs.  Harvey  B,  Matthews,  Alfred  C.  Beck  and  George 
W.  Phelan,  who  have  aided  me  materially  by  their  detailed  study  of 
case  histories  and  their  helpful  criticism,  and  to  my  artists,  Mr.  Howard 
Shannon  and  Miss  Emily  Freret,  as  well  as  to  my  publishers,  who  have 
so  courteously  cooperated  with  me  in  making  this  monograph  a  reality. 

J.  O.  P. 
Brooklyn,  N.  Y. 


CONTENTS 

HAPTER  PAGE 

I.    Infections  of  the  Vulva,  Vagina  and  Cervix i 

Infections  of  Skene's  glands,  i — Inflammation  and  abscess  of  Bartho- 
lin's ducts  and  glands,  3 — Excision  of  Bartholin's  glands,  5 — In- 
flammation of  the  vulva,  5 — Simple  vulvitis,  5 — Chronic  vulvitis,  6 
— Follicular  vulvitis,  S^Diabetic  vulvitis,  9 — Inflammation  of  the 
vagina,  9 — Gonorrheal  vaginitis,  11 — Granular  vaginitis,  11 — Senile 
vaginitis,  12 — Acute  endocervicitis,  14 — Chronic  endocervicitis,  14— 
Differential  diagnosis,   19 — Operative  treatment,  24. 

XL    Gonorrhea 3^ 

General  considerations  regarding  gonorrhea,  31 — Frequency  of  gonor- 
rhea, 35 — Gonorrheal  vulvitis,  37 — Condyloma  acuminata,  zi — Ure- 
thritis and  bartholinitis,  38 — Gonorrheal  vaginitis,  39 — Cervical  gonor- 
rhea, 39 — Gonorrheal  endometritis,  41 — Histology,  42 — Differential 
diagnosis,  44 — Histology  of  chronic  endometritis,  44 — Pathology  and 
histology  of  gonorrheal  metritis,  45 — Gonorrheal  inflammation  of  the 
fallopian  tubes,  46 — Characteristics  peculiar  to  gonorrheal  infection, 
46— Microscopical  appearances  of  gonorrheal  salpingitis,  47— Pyosal- 
pinx,  47 — Gonorrheal  inflammation  of  the  tubes  and  ovaries,  48 — 
Acute  pelvic  inflammation,  51 — Chronic  pelvic  inflammation,  52 — 
Treatment  of  gonorrheal  infections,  53 — Acute  specific  urethritis,  57 — 
Acute  specific  vaginitis,  58. 

III.  Pelvic  Infections 62 

Pelvic  infections,  62 — Bacteriology,  63— Mode   of   invasion,  65. 

IV.  Puerperal  Infections 67 

Puerperal  infections,  67 — Avenues  of  entrance  for  bacteria,  6"] — Birth 
traumatisms,  67 — Bacteria  of  the  genital  region,  68 — Primary  local 
infection,  69 — The  puerperal  endometrium,  70 — Antepuerperal  endo- 
metritis, 71 — Frequency,  74 — Vulvar  infection,  75 — Coccal  endometritis, 
80— Cellulitis,  81 — Parametritis  and  perimetritis,  81 — Differential 
diagnosis  of  cellular  inflammation,  92, 

V.    Puerperal  Infections    (Continued) 95 

Infections  of  the  veins,  95 — Thrombophlebitis  of  the  femoral  or  of  the 
saphenous  veins,  95 — Puerperal  pyemia,  97 — Treatment  of  the  in- 
fections of  the  femoral  and  pelvic  veins,  98 — Radical  treatment,  loi 
— Bacteriemia,  102 — Avenues  of  entrance,  102— Prognosis  in  puerperal 
infections,  105 — Treatmpnt  of  puerperal  infections,  107 — Parametritis 
and  perimetritis,  113— Pelvic  peritonitis,  115— Operative  measures,  118 
— Transfusion  of  citrated  blood,  121— Gas  bacillus  infection,  121. 

VI.    Fibrosis  Uteri  Metritis,  Subinvolutions 123 

Invasion  of  endometrium  by  infective  bacteria.  123— Gross  pathology 
of  chronic  metritis,  subinvolution  and  uterine  hypertrophy,  124— Con- 
ditions which  hinder  normal  involution,  127 — Some  change  in 
menstruation  characteristic  of  metritis  or  subinvolution,  128— Throm- 
bokinase,  129 — Hemorrhage  the  most  common  symptom,  129 — Treat- 
ment by  rest,  hot  douches,  vaginal  tamponade,  galvanism,  drugs, 
radium,  133— Surgical  treatment,  134— -Curettage,  135— Hysterectomy, 
136. 

vii 


viii  CONTENTS 

CIlArTER  ^**'^ 

VII.    Salpingitis i35 

Four  routes  of  infection,  137 — Sepsis  and  gonorrhea  the  most  common 
causes  of  salpingitis.  137 — Acute  salpingitis,  138 — Hydrosalpinx,  140 
Clinical  phenomena,  142— Significance  of  the  history,  143 — Physical 
signs  of  pyosalpinx,  144 — Differential  diagnosis,  146— Hydrosalpinx, 
147 — Hematosalpinx,  147 — Gonorrheal  salpingitis,  149 — Treatment  of 
acute  salpingitis,  152 — Technic  of  vaginal  section  (posterior  colpot- 
omy).  155 — Treatment  of  chronic  salpingitis,  160 — Salpingostomy, 
i6o^Technic  of  salpingectomy,  161 — Radical  treatment,  168— 
Technic,  170. 

\'III.    Ovaritis 187 

Mode  of  invasion  and  etiology  in  ovaritis,  187 — Pathology,  188 — Usually 
a  history  of  gonorrheal  infection,  188— Chronic  ovaritis,  i8g — 
Atrophic,  hyperplastic  and  cystic  forms,  190 — Sterility,  191 — Treat- 
ment of  chronic  ovaritis,  191. 

IX.    Pelvic  Peritonitis 193 

Causes  of  pelvic  peritonitis,  193 — Gonococcic  pelvic  peritonitis,  193 — 
Pyogenic  peritonitis.  194— Symptoms :  chill,  pain,  pulse,  muscular 
rigidity,  abdominal  tension,  tympanites,  nausea  and  vomiting,  consti- 
pation, 195— Physical  signs,  197— Treatment  of  pelvic  peritonitis,  198 
— Arrest  of  intestinal  peristalsis,  200. 


Tuberculous    Peritonitis 

Tubercle  bacilli  in  the  peritoneum,  203— Secondary  involvement  by  the 
blood  stream  by  contiguity  or  by  continuity,  205— No  well  defined 
sj-mptomatology,  206— Exudative,  adhesive  and  caseous  forms,  207— 
Clinical  diagnosis  difficult,  209— Prognosis,  211— Climate,  212— 
Tuberculin,  212— Operation,  213. 


204 


Index 


215 


ILLUSTRATIONS 

PLATES 

I.     Streptococcic  endometritis  removed  at  autopsy  showing-  how  the  kidney 

participates    in    virulent    infections       ....         FrontispieCf 
II.     Uterus    removed    from    patient    dying    of    streptococcic    endometritis, 

.  postabortal    type;    placenta    in    situ       ....         Frontispiece 

FIGURE  PAGt. 

1.  Everting  the  mucosa  of  the  urethra  with  the  finger  in  the  vagina  and 

milking   Skene's   ducts   of   pus      .......         2 

2.  A.  Infected   cyst    of    Bartholin's    gland,    extending   backward    toward 

the  corrimissure   ..........         4 

B.  Incision   exposing   distended   gland        ......         4 

C.  Gland   removed — sutures   in   place  ......         4 

3.  Cystic  cervicitis  resulting  from  infection  of  a  cervix  laceration    .  .        15 
•  4.     Cone  taken   from   infected  cervix,   showing  points  from  which   serial 

sections   were    made    .........        17 

5.  Appearance    of    excised    cone,    showing    muscle    tissue    replaced    by 

fibrous   tissue       ..........        18 

6.  Chronic   endocervicitis   treated  by   linear   cauterization      ...       21 

7.  Same  cervix  after  linear  scars  made  by  cautery  are  healed  .  .  .22 

8.  Twenty-five  milligrams  of  radium  in  a  brass  filter  placed  in  the  cervix       22 

9.  Tenacula  on  the  anterior  and  posterior  lips  of  the  cervix  within  the 

margin  of  the  eroeaon  .........       23 

10.  The  same  procedure  may  be  used  in  infected  lacerations    ...       24 

11.  Incision  circling  the  limits  of  the  erosion    ......       25 

12.  The  portial  mucosa  is  then  pushed  back  to  make  the  cuff    ...       25 

13.  With   sharp   pointed   Emmet's   scissors   the   glandular   portion   of  the 

cervix  is  coned  out     .........       26 

14.  A  single  tenaculum  is  introduced  into  the  uterine  canal  and  the  two 

catgut  sutures  are  held  taut;  this  brings  the  uterus  down  nearer 

the  vulva     ...........       27 

15.  Sagittal  section  of  the  inverting  stitch      .  .  .  .  .  .28 

16.  When  this  is  drawn  taut,  the  portial  mucosa  is  in  contact  with  the 

mucosa  of  the  canal     .........       28 

17.  A  silkworm  gut   stitch  is  next  passed,   as  per  diagram,   through   the 

portial  mucosa   and   into   the   canal      ......       29 

18.  When  all  stitches  are  tied — the  erosion  is  replaced  with  vaginal  mucosa       29 

19.  Diagrammatic   drawing,   showing  the   course   of  gonorrheal   infection 

through  the  uterus  to  the  peritoneum    ......       32 

20.  Photograph  from  author's  collection,  showing  how  a  double  pyosalpinx 

rolls  over  and  covers  the  ovary.     Both  tubes  are  adherent  in  the 

cul  de  sac    ...........       49 

21.  Diagram   illustrating   routes    of   puerperal    infections    from   puerperal 

wounds  through  the  lymphatics,  placental  site  and  venous  radicals 

(in    colors)  .  .  .  .  .  .  .  •  .  •       ^7 

ix 


y  ILLUSTRATIONS 

FIGURE  PAGE 

22.  A  relaxed  uterus  after  a  curetted  abortion.    It  allows  the  barium  solu- 

tion to  be  forced  into  the  veins.     (Sampson)      ....       68 

23.  When   the   endometrium   is   intact   and  the   uterus   contracted   barium 

solution  cannot  be  forced  into  the  veins.     (Sampson)    ...       69 

24.  When  the  endometrium  is  injured  the  barium  solution  may  be  forced 

into    the    veins.      (Sampson)       .  .  .         .         .         .         •       '7'2 

25.  Veins  injected  with  barium  solution.     (Sampson)      ....       72 

26.  Barium   injected   into  the   contracted   uterus   can   be   forced   into   the 

tubes.     (Sampson)       .........       1^ 

27.  Relaxed  uterus  with  tube  injected  with  barium  solution.     (Sampson)       78 

28.  Showing  the   cellular   tissue   lying-   under   the   pelvic   peritoneum   and 

above  the  levatores  ani  muscles    .......       82 

29.  Transverse  section  through  pelvis  at  the  level  of  the  internal  os,  show- 

ing how  the  cellular  tissue  spreads  from  the  uterus  as  a  center, 
each  part  reaching  the  pelvic  wall      ......       83 

30.  Sagittal  section  showing  the  relation  of  the  pelvic  cellular  tissue  to 

the   bladder   and   the    rectum       .  .  .         .  .  .  •       8^ 

31.  Exudate  into  the  lateral  parametrial  tissues,  displacing  the  uterus  and 

obliterating  the  fornices  and  vaginal  portio    .....       86 

32.  As  the  exudate  organizes  and  the  scar  tissue  contracts,  the  uterus  is 

drawn  toward  the  side  of  the  exudate        .....       88 

33.  Fowler  position  by  blocks  under  head  of  bed     .....     109 

34.  Ill's  method  of  treating  putrid  endometritis  with  alcohol  irrigations     .     112 

35.  Site   of   incision   just   above   Poupart's   ligament,   with    a   "Cigarette" 

drain  between  the  folds  of  the  broad  ligament     .  .         .  .114 

36.  Harris  Drip — Patient  on  gatch  frame.     Glucose  and  soda  solution  at 

same  level  in  both  can  and  rectum     .         .  .  .  .  .114 

37.  Diagrammatic  sagittal  section  showing  isolation  of  pelvis  in  pelvic  in- 

flammation.    Patient  in   Fowler  position      .  .  .  .  •      ii5 

38.  Placing  the   gauze   roll   drains.     The   posterior   vaginal   incision  held 

open  with  long  bladed   rectractors      .  .  .  .  .  .116 

39.  Counter  incision  and  drainage  through  the  loins  in  purulent  peritonitis     117 

40.  Suprapubic    "stab   drain"    in    spreading   peritonitis.      Courtesy    of    D. 

Appleton  &  Co.     From  Polak's  "Pelvic  Inflammation"  .  •      n? 

41.  Drawing  from  autopsy  and  operating  table  pathology,  showing  isolation 

of   pelvis   in    a    case    of   postabortive    peritonitis,    favored   by   the 
Fowler  elevated  trunk  posture     .  .  .  .  .  .  .118 

42.  Drawing   from    specimen   in   author's   collection   showing  increase   in 

constituent  elements,  the  thickened  decidua  of  pregnancy  and  early 
placenta    formation       .........      125 

43.  A  pyosalpinx  showing  how  the  tube  rolls  over  the  ovary  and  drops  into 

the  cul  de  sac     ..........     137 

44.  Double  hydrosalpinx   from  the  author's  collection      ....      138 

45.  Specimen    of    pyosalpinx    from    the    author's    collection    showing    in- 

flammatory nodes  in  the  isthmus  ......      139 

46.  Suppurating  salpingitis  on  one  side  with  a  pyosalpinx  on  the  other     .      140 

47.  A  pyosalpinx  on  one  side  and  a  tubo-ovarian  abscess  on  the  other. 

From  the  author's  collection        .......     I4S 


ILLUSTRATIONS 


48.  Acute  red  degeneration  of  a  myoma  complicating  pregnancy.    Sudden 

onset,  acute  pelvic  and  abdominal  pain  and  fever  rise  in  pulse  and 
leukocytosis,  with  rapid  increase  in  size  of  tumor  mass,  which  be- 
came  exquisitely   sensitive,   simulating   an   acute   abscess 

49.  Drawing   from  operation   showing  how   sigmoid   and   omentum   close 

off  the  general  peritoneal  cavity  in  pelvic  inflammation 

50.  Technic   of  posterior   vaginal   section,    showing   point   of   incision 

51.  Technic    of   posterior    vaginal    section       ..... 

52.  The  scissors  are  then  discarded  and  the  finger  is  introduced  through 

the  incision  in  the  vaginal  mucosa      ..... 

53.  Widening  the  incision  with  the  fingers      ..... 

54.  Gauze  rolls  placed  in  the  cul  de  sac  for  drainage  preferable  to  a  tube 

55.  Areas  of  serial  sections     ........ 

56.  Cell  reaction  in  tubal  section  showing  small  round  mucosa    . 

57.  Areal   sections   showing   reaction   about   and   remote   from   interstitial 

portion  of  tube    ........ 

58.  Areal  section  showing  inflammatory  reaction  remote  from  tubal  en 

trance  ........... 

59.  Freeing  the  tube  from  its  mesosalpinx,  ligating  the  individual  vessel: 

and  not  interfering  with  the  ovarian  circulation    . 

60.  Extent  of  wedge  excisions  from  fundus  and  body     . 

61.  Lines  of  incision  in  making  a  partial  resection  of  the  uterus 

62.  Bringing  of  uterine  flaps  together  with  interrupted  sutures 

63.  Peritonealization  of  wound  by  detaching  the   bladder   and   reflecting 

the  flap  over  the  suture  line — the  ovaries  are  suspended  by  sutur- 
ing them  to   round  ligaments      ..... 

64.  Inter-ovarian  circulation    ....... 

65.  Conserving    the    ovarian    circulation    by    pushing    the    utero-ovarian 

anastomosis  off  into  the  folds  of  the  cross  ligament     . 

66.  Ligation  of  the  uterine  artery — mesosalpinx  and  ovarian  ligament  in 

grasp  of  a  hemostat  forceps        ...... 

67.  Removal  of  uterus  with  rourfd  ligament  sewn  into  stump    . 

68.  Conservation  of  ovary  and  tube  by  suture  suspension  to  round  liga 

ment   ........... 

69.  The  uterus  is  drawn  out  of  the  wound  by  a  large  Jacob's  forceps 

70.  Clamping  of  the  infundibulopelvic  and  round  ligaments  and  ligaments 

tied  distal  to  the  clamp      ...... 

71.  Cutting  ligaments  between  clamp  and  ligature    . 

72.  Freeing  the  vesico  reflection  of  the  peritoneum  from  the  uterus 
72,-     Carrying  anterior  bladder  reflection  over  vaginal  vault 

74.  Retraction  of  bladder  and  exposure  of  uterine  artery 

75.  Clamping  and  cutting  of  uterine  artery     .... 

76.  Drawing  forward  of  uterus  while  incision  is  carried  across  the  pos 

terior  peritoneal  fold    ....... 

"^y.     Forcing  of  curved  scissors  into  vagina     .... 

78.  Enlarging  vaginal  incision  at  the  cervicovaginal  section  with  scissors 

79.  Drawing  up  of  cervix  through  vaginal  incision  ..... 


146 

150 

152 

153 
154 

155 
160 
161 

162 

163 

164 
164 
165 

165 

166 
167 

167 

168 
169 

170 
171 

172 
173 
174 
174 
175 
176 

177 
178 
179 
180 


ILLUSTRATIONS 


80.  Sterilization  of  vaginal  portion  of  the  cervix     .         .         . 

81.  Exposure  of  the  posterior  cervicovaginal  junction     . 

82.  Closure  of  vaginal  vault  vi^ith  figure  of  eight  sutures    . 

83.  Sutures  tied  and  used  as  tractors     ..... 

84.  Passing  of  ligatures  about  the  uterine  and  vaginal  branches 

85.  Drawing  round  ligament  into  the  stump     .  . 

86.  Sewing  of   round  ligaments  into  the   stump  and  beginning  of 

tonealization         ........ 

87.  Peritonealization  of  the  raw  surfaces        .... 

88.  Finished  operation  when  ovary  and  tube  can  be  conserved 

89.  Completed  operation  when  both  ovaries  have  been  conserved 


peri- 


PAGE 

181 
181 
182 
182 

183 

183 

184 
184 

185 

i8S 


PELVIC   INFLAMMATION 
IN  WOMEN 


PELVIC  INFLAMMATION  IN  WOMEN 

CHAPTER  I 

INFECTIONS   OF  THE  VULVA,  VAGINA  AND   CERVIX 

Infections  of  Skene's  glands — Inflammation  and  abscess  of  Bartholin's  ducts  and 
glands — Excision  of  Bartholin's  glands — Inflammation  of  the  vulva — Simple  vul- 
vitis— Chronic  vulvitis— Gonorrheal  vulvitis — Follicular  vulvitis — Diabetic  vul- 
vitis—Inflammation  of  the  vagina— Gonorrheal  vaginitis— Granular  vaginitis- 
Senile  vaginitis — Acute  endocervicitis — Chronic  endocervicitis — Differential  diag- 
nosis— Operative  treatment. 

Infections  of  the  female  genital  organs  make  up  such  a  large 
group  of  the  diseases  peculiar  to  women,  and  their  pathology  and  treat- 
ment are  so  distinct  because  of  the  special  anatomy  of  the  genital  tract, 
that  it  is  but  proper  that  these  infections  should  be  discussed  apart  from 
the  other  pathological  conditions  which  may  affect  the  female  genitalia. 

Before  taking  up  a  discussion  of  the  inflammatory  diseases  which 
are  directly  the  result  of  labor,  abortion,  and  mixed  or  gonorrheal  infec- 
tion spreading  from  acute  cervical  and  endometrial  lesions,  we  will  re- 
view the  infections  of  the  vulva,  introitus,  vagina,  and  cervix,  and  thus 
give  the  reader  a  consecutive  view  of  the  acute  and  subacute  inflamma- 
tions as  they  involve  the  successive  tissues.  In  acute  gonorrheal  infection 
as  Skene's  glands,  and  the  ducts  of  Bartholin,  are  the  most  common 
points  of  infection. 

INFECTIONS    OF    SKENE's    GLANDS 

Skene's  glands,  or  the  para-urethral  ducts,  are  two  small  tubules  which 
lie  on  each  side  near  the  floor  of  the  female  urethra  and  extend  up  from 
the  meatus  urinarius  for  about  three  fourths  of  an  inch;  these  ducts 
open  just  anterior  to  the  center  of  the  urethral  lips.  Koch  maintains 
that  they  represent  the  lower  extremities  of  the  wolffian  ducts ;  other  au- 
thorities, however,  maintain  that  they  are  simply  exaggerated  lacunae. 
Their  chief  interest  lies  in  the  fact  that  gonorrheal  invasion  of  these 
ducts  is  the  most  persistent  lesion  with  which  the  gynecologist  has  to  deal, 
for  the  gonococcus  may  remain  indefinitely  buried  beneath  the  lining 


PELVIC  INFLAMMATION  IN  WOMEN 


cells  of  the  tubule  and  may  cause  a  chain  of  symptoms  referable  to  the 
urinary  tract,  as  chronic  urethritis,  with  its  frequent  and  burning  urina- 
tion, or  a  persistent  infective  discharge,  which  in  turn  carries  the  in- 
fection higher  up  to  the  cervix  and  uterus. 

Diagnosis. — The  diagnosis  is  made  by  exposing  the  mouth  of  the 

tubules.  This  is  done 
by  everting  the  ure- 
thral mucosa,  the  fin- 
ger in  the  vagina  mak- 
ing pressure  against 
the  urethra  from  with- 
in outward  along  its 
course.  By  this  ma- 
nipulation a  drop  of 
pus  may  be  expressed 
from  the  mouth  of  each 
tubule,  which  is  situ- 
ated just  within  the 
meatus  on  either  side 
of  the  floor  of  the 
urethra.  The  presence 
or  absence  of  the  gono- 
cocciis  should  always 
he  demonstrated  in  the 
pus  hy  the  microscope 
before  treatment  is  in- 
stituted. Occasionally 
the  outer  orifices  of 
the  ducts  may  be  closed 
as  a  result  of  the 
inflammatory  process, 
when  an  abscess  may 
form  in  the  tubule  and 
suburethral  tissues.  The  abscess  usually  discharges  spontaneously 
through  the  tuhide. 

Treatment. — Destruction  of  gonococcic  infection  in  this  location 
may  be  accomplished  either  by  (a)  injection  or  (b)  cauterization.  After 
cocainizing  the  meatus  and  the  urethra,  by  inserting  into  the  urethra  a 
pledget  of  cotton  wet  with  a  ten  per  cent  solution  of  cocain,  which  is 
left  in  place  for  five  or  ten  minutes,  a  probe  pointed  hypodermic  needle 
is  inserted  into  the  duct,  and  a  drop  of  pure  carbolic  acid,  or  25  per 


Fig.  I. — Everting  the  Mucosa  of  the  Urethra  with 
THE  Finger  in  the  Vagina  and  Milking  Skene's 
Ducts  of  Pus. 


INFECTIONS  OF  THE  VULVA,  VAGINA  AND  CERVIX  3 

cent  silver  nitrate  solution,  is  injected  into  the  tubule.  The  treatment 
may  have  to  be  repeated  several  times  at  intervals  of  about  a  week.  A 
more  satisfactory  method  is  that  of  splitting  open  the  ducts  with  the 
electric  cautery.  Under  local  anesthesia  a  fine  pointed  cautery  knife 
is  passed  into  the  duct,  the  current  turned  on,  and  the  tubule  slit  upward 
into  the  urethral  floor.  The  tract  is  then  cauterized,  destroying  the 
tubule  and  its  contents. 

INFLAMMATION    AND   ABSCESS   OF    BARTHOLIN'S    DUCTS    AND    GLAND 

The  Bartholin  duct,  which  is  found  just  within  the  vulvovaginal 
orifice,  opens  external  to  the  hymen  in  nulliparous,  and  below  the  caruncle 
in  parous  women.  It  is  the  external  outlet  of  the  gland;  the  vulvovaginal 
gland  lies,  as  a  rule,  behind  the  anterior  layer  of  the  triangular  ligament, 
or  may  lie  behind  or  in  front  of  the  posterior  layer.  In  structure  it  is  a 
compound  tubular  gland,  which  secretes  a  thin  translucent  fluid  and  is 
the  homologue  of  Cowper's  gland  in  the  male.  Both  glands  and  ducts 
are  Hned  with  tall  columnar  epithelium.  The  duct  alone  may  be  involved, 
or  the  infection  may  extend  to  the  gland.  It  is  usually  a  bilateral  in- 
volvement. When  the  inflammation  is  confined  to  the  duct  and  its 
lining  epithelium,  the  orifice  of  the  duct  is  red  and  swollen  and  a  purulent 
discharge  escapes  on  pressure.  Long  after  all  of  the  acute  manifesta- 
tions of  the  infection  have  disappeared,  the  red  raised  macula  about  the 
orifice  will  point  to  the  origin  of  the  infection,  for  it  seems  impossible 
without  destruction  of  the  duct  to  completely  eradicate  the  latent  gonococ- 
cus.  The  infection  extends  along  the  duct  to  the  gland,  and,  as  a  result 
of  the  inflammation,  the  tube  lumen  may  become  obliterated,  and  a  col- 
lection of  pus  forms  within  the  gland  itself,  distending  it  and  forming 
an  abscess.  The  bacteriology  of  the  abscess  content  will  usually  show 
staphylococci  alone  or  in  combination  with  the  gonococcus. 

Symptoms  and  Physical  Signs  of  Bartholin  Gland  Infection. 
— The  patient  complains  of  a  vulvar  swelling  on  one  or  both  sides  of 
the  labia  minora,  and  other  general  symptoms  of  a  local  inflammation : 
on  inspection,  the  usual  evidences  of  inflammation,  such  as  redness  and 
swelling,  are  to  be  seen.  The  orifices  of  the  duct  or  ducts  are  red  and 
swollen,  and  there  is  an  ovoid  tumor  in  one  or  both  labia,  more  or  less 
occluding  the  orifice  of  the  vagina.  The  overlying  tissues  of  the  labia 
are  red,  hot,  and  painful,  and  the  tumor  rapidly  enlarges;  the  enlarge- 
ment extends  backward  toward  the  commissure  and  upward  into  the 
submucous  tissues  of  the  vagina.  There  is  usually  a  slight  elevation  of 
temperature. 

Abscess  of  the  Bartholin  gland  must  be  differentiated  from  a  pudendal 


PELVIC  INFLAMMATION  IN  WOMEN 


hernia,  a  retention  cyst  of  the  vulvovaginal  gland,  inclusion  cysts  of 
the  lower  vaginal  wall,  and  vulvar  tumors.  A  hernia  presents  none  of 
the  pain  and  sensitiveness  of  a  gland  infection,  neither  is  there  the 
history  or  other  evidence  of  gonorrheal  exposure ;  and  usually  one  or 
more  of  the  usual  signs  of  hernia  are  demonstrable  in  the  tumor,  namely, 
an  impulse  on  coughing,  reducibility  in  the  recumbent  position,  evidence 
of  intestinal  obstruction,  and  resonance  on  percussion.     A  retention  cyst 

of  the  vulvovaginal  gland 
has  none  of  the  inflamma- 
tory symptoms  which 
characterize  an  abscess, 
the  swelling  is  ovoid  but 
not  painful,  its  growth  is 
slower  and  the  overlying 
skin  and  mucosa  may  be 
moved  freely  over  it.  As- 
piration of  the  contained 
fluid  will  always  make  the 
diagnosis  positive.  In- 
clusion cysts  of  the  lower 
vaginal  wall  are  rare, 
usually  solitary,  and  vary 
in  size  from  that  of  a  pea 
to  that  of  a  cocoanut. 
The  mucous  membrane 
of  the  vagina  moves 
freely  over  the  surface  of 
the  tumor.  If  the  cyst  is 
on  the  posterior  wall, 
rectovaginal  touch  will 
quickly  reveal  its  limita- 
tions. Vulvar  tumors  are  distinguished  by  their  density  and  usually 
are  devoid  of  inflammatory  phenomena. 

Treatment. — It  may  be  possible  to  dilate  the  Bartholin  duct  with 
a  probe  and  allow  the  contained  purulent  fluid  to  escape.  A  probe  pointed 
hypodermic  needle,  attached  to  a  syringe  containing  a  dram  of  a  25 
per  cent  argyrol  solution,  may  then  be  passed  through  the  duct  and 
injected  into  the  gland  cavity.  This  treatment  may  be  repeated  daily, 
if  the  lumen  of  the  duct  will  permit.  Unfortunately  it  is  painful  and 
is  neither  as  satisfactory  nor  as  permanent  as  incision  or  excision  of 
the  abscess  cavity. 


Fig.  2. — A.     Infected  Cyst  of  Bartholix's  Gland, 
Extending   Backward  toward  the   Commissure. 

B.  Incision    Exposing    Distended    Gland. 

C.  Gland  Removed — Sutures  in  Place. 


INFECTIONS  OF  THE  VULVA,  VAGINA  AND  CERVIX  s 

Incision. — After  thoroughly  preparing  the  vulva  by  cutting  away  the 
hair,  cleansing  the  region  of  operation,  and  then  painting  it  with  tincture 
of  iodine  three  and  one  half  per  cent,  the  tissues  about  the  tumor  should 
be  infiltrated  with  a  one  half  per  cent  solution  of  novocain.  When  the 
anesthesia  is  complete,  the  abscess  may  be  emptied  by  a  free  incision  over 
the  gland  on  its  mucous  surface,  just  within  the  labia,  at  the  junction  be- 
tween the  skin  and  mucous  membrane.  While  this  allows  the  escape 
of  pus,  extirpation  or  destruction  of  the  gland  membrane  is  necessary  to 
prevent  recurrence.  This  may  be  done  with  a  sharp  curet,  or  by  the  ap- 
plication of  pure  carbolic  acid  to  the  abscess  cavity.  After  the  capsule  has 
been  removed  or  destroyed  in  this  way,  a  firm  gauze  pack  should  be  left 
in  situ  for  several  days.  In  the  author's  hands  nitrous  oxide  and  oxygen 
anesthesia  is  preferable  to  local  infiltration. 

Excision  of  the  Gland  is  applicable  alike  to  abscess  or  cyst,  and  when 
done  properly,  has  many  advantages  over  incision,  as  it  insures  extirpa- 
tion of  the  entire  gland.  Under  local  or  general  anesthesia,  the  abscess 
cavity  or  cyst  may  be  emptied  of  its  contents  through  an  aspirating 
needle;  then,  without  withdrawing  the  needle,  the  cavity  is  injected  with 
melted  paraffin  wax;  this  promptly  solidifies  within  the  limits  of  the 
gland  and  makes  it  possible  to  remove  the  entire  sac  without  perforating 
the  gland  capsule.  After  the  paraffin  has  set,  an  incision  parallel  to  the 
labia  is  made  through  the  mucocutaneous  margin  and  the  gland  enucleated 
by  blunt  dissection.  After  the  control  of  bleeding  by  pressure,  or  by 
ligature  of  the  individual  vessels,  the  wound  may  be  closed  by  sutures, 
providing  drainage,  by  the  insertion  of  a  narrow  strip  of  rubber  tissue 
in  the  posterior  angle  of  the  wound. 

INFLAMMATION  OF  THE  VULVA 

Vulvitis  is  an  inflammation  of  the  tissues  making  up  the  vulva. 
It  may  be  studied  under  the  following  headings:  i.  Simple  vulvitis,  2. 
gonorrheal  or  specific  vulvitis,   3.   follicular  vulvitis,   4.   diabetic  vulvitis. 

Simple  Vulvitis. — Simple  vulvitis  is  an  inflammation  of  the  vulva 
which  is  characterized  by  free  serous  or  mucopurulent  discharge,  swell- 
ing, and  heat.     It  may  be  either  acute  or  chronic. 

Causes. — It  may  be  caused  by  uncleanliness,  traumatism,  chafing,  or 
parasites  (as  the  pediculi  pubis,  seat  worms,  or  saprogenic  microbes),  or 
by  irritating  discharges  from  the  uterus,  vagina,  or  bladder,  or  by  exces- 
sive coitus,  or  masturbation,  or  diathesis.  It  is  comparatively  rare  and  is 
seen  most  often  in  children  and  young  girls  with  delicate  epithelial  sur- 
faces and  in  obese  women. 

Symptoms. — In  the  acute  non-specific  form  the  patient  complains  of 


6  PELVIC  INFLAMMATION  IN  WOMEN 

local  irritation,  tenderness,  and  pain  and  smarting  on  urination  as  the 
urine  passes  over  the  inflamed  areas.  The  labia  are  painful,  swollen,  red 
and  hot.  The  discharge  is  profuse  and  mucopurulent  and  has  a  fetid  odor; 
and  the  external  vulvar  surfaces  and  inner  surfaces  of  the  thighs  become 
excoriated,  primarily  from  scratching  due  to  the  existing  pruritus.  A 
dermatitis  is  likely  to  follow.  Occasionally  the  mucous  glands  are  ob- 
structed and  a  form  of  acne  develops.  The  inguinal  glands  may  be 
enlarged  and  cause  pain  in  both  groins. 

In  chronic  znilvitis  the  itching  and  burning  are  prominent  symptoms. 
The  itching  may  be  so  severe  as  to  preclude  rest.  There  is  less  swelling, 
the  discharge  is  thinner,  of  a  serous  character,  and  less  profuse,  but 
excoriations  due  to  scratching  are  constant  lesions;  in  fact  the  inner 
surfaces  of  the  thighs  are  often  inflamed  and  eroded. 

Treatment. — The  treatment  of  simple  acute  vulvitis  may  be  sum- 
marized as  follows:  (i)  Removal  of  the  cause,  (2)  physical  rest,  (3)  fre- 
quent cleansing  and  local  medication.  Irrigations  with  a  warm  borax 
solution,  one  dram  to  the  quart,  for  cleansing.  Care  must  be  exercised 
that  none  of  the  solution  enters  the  vagina  and  forces  the  infection  higher 
up.  Sitz  baths  of  borax  water  of  one  half  to  one  hour  duration  help 
to  reduce  the  local  swelling. 

They  should  be  taken  twice  daily  and  followed  by  rest  in  the  recum- 
bent posture.  Sedative  lotions,  like  lead  and  opium,  or  a  saturated  solu- 
tion of  aluminum  acetate,  appHed  to  the  inflamed  parts,  tend  to  relieve  the 
pain.  Separation  of  the  labia  with  antiseptic  compresses  secures  free 
exit  for  the  secretions  and  prevents  agglutination  of  the  labial  edges.  A 
saline  laxative  should  be  taken  each  night  before  retiring  to  secure  free 
action  of  the  bowels;  while  the  urine  must  be  rendered  bland  and  non- 
irritating  by  the  copious  ingestion  of  alkaline  waters.  Food  likewise 
should  be  light  and  nourishing,  without  condiment.  Coffee  and  all  alco- 
holic beverages  should  be  prohibited. 

Chronic  Vulvitis. — The  same  general  rules,  as  to  cleanliness  and  the 
condition  of  the  urine,  apply  in  the  treatment  of  chronic  cases.  The 
cause,  however,  is  more  easily  determined,  hence  the  treatment  is  less 
empiric.  When  the  vulvitis  is  due  to  parasites,  oleate  of  mercury  and 
mercurial  ointment  are  useful. 

Irritating  discharges  from  the  vagina,  cervix,  or  uterus,  should  receive 
appropriate  local  treatment.  Diatheses  demand  proper  local  and  hygienic 
attention.  Excessive  coitus  or  masturbation  should  be  prohibited.  Local 
measures  for  the  correction  of  the  associated  dermatitis  and  pruritus  are 
usually  required.  These  consist  of  thorough  cleansing  of  the  vulvar 
surfaces  with  "Synol"  soap,  irrigation  and  the  application  of  mild  astrin- 


INFECTIONS  OF  THE  VULVA,  VAGINA  AND  CERVIX  7 

gents  and  antiseptics,  as  weak  solutions  of  permanganate  of  potassium, 
mercuric  bichlorid,  carbolic  acid.  Lint  compresses  wet  with  an  aqueous 
solution  of  argyrol  should  be  placed  between  the  labia  to  keep  them  sepa- 
rated. As  the  dermatitis  subsides  the  parts  should  be  kept  dry  and  dusted 
with  bland  powders,  as  stearate  of  zinc,  cornstarch,  or  lycopodium. 

Gonorrheal  Vulvitis. — This  is  a  specific  inflammation  of  the  vulva 
caused  by  the  gonococcus.  It  is  estimated  that  about  75  per  cent  of  the 
cases  of  vulvitis  are  of  gonorrheal  origin.  It  is  characterized  by  an  in- 
creased burning  during  micturition,  profuse  purulent  discharge,  and 
redness  of  the  meatus  and  the  orifices  of  Bartholin's  ducts.  The  disease 
has  a  marked  tendency  to  spread  to  the  adjacent  structures,  involving  the 
urethra,  cervix,  uterus,  tubes  and  ovaries.  The  lesions  and  symptoms  are 
usually  of  greater  intensity  than  are  found  in  the  simple  type.  Gonor- 
rheal vulvitis  may  be  epidemic  in  children,  the  disease  running  through 
schools  and  hospital  wards.  The  presence  of  the  hymen  seems  to  act 
as  a  protection  to  the  little  girl  against  upward  invasion  of  the  gonococcus, 
though  the  urethra,  Bartholin's  and  Skene's  glands  are  all  promptly 
invaded. 

Symptoms. — Within  a  few  days  after  suspicious  coitus  or  exposure 
to  infection,  the  vulva  becomes  irritated  and  heat,  pain,  redness  and 
swelling  of  the  vulvar  tissues  are  noted;  the  pathologic  changes  are 
always  more  pronounced  than  in  non-specific  vulvitis.  The  urethra 
rapidly  becomes  involved  and  the  gonococcus  may  be  determined  by  the 
microscope.  Gonorrheal  infection,  except  in  children,  generally  extends 
or  is  carried  by  the  treatment,  to  the  internal  genital  organs.  The  in- 
flammatory reaction  is  most  severe  in  virgin  tissues.  The  vulvovaginal 
glands  (Bartholin's)  and  the  Skene's  tubules  just  within  the  meatus 
are  almost  always  infected  in  a  gonorrheal  vulvitis.  No  case  of  acute 
vulvitis  should  be  classed  as  gonorrheal,  no  matter  how  strong  the  clinical 
evidence,  unless  the  gonococcus  can  be  demonstrated  in  the  discharge ;  and 
yet  the  absence  of  the  gonococcus  is  not  positive  proof  against  the  specific 
character  of  the  disease,  as  the  gonococcus  is  capable  of  assuming  amor- 
phous forms  and  remaining  quiescent  for  years,  only  to  resume  its  orig- 
inal form  and  virulence  under  proper  irritation. 

Treatment. — The  treatment  of  acute  gonorrheal  vulvitis  presents 
four  definite  purposes  on  the  part  of  the  attendant,  (i)  to  obtain  local 
cleanliness^  (2)  to  prevent  extension  of  the  infection  to  other  structures, 
(3)  to  eradicate  the  infection  hy  destruction  of  the  gonococcus,  and 
finally  (4)  to  impress  upon  both  patient  and  nurse  the  contagiousness 
of  the  disease  and  the  dangers  of  accidental  infection  of  eyes,  rectum,  etc. 
Patients  suffering  from  acute  gonorrheal  vulvitis  should  be  placed  in  bed 


8  PELVIC  INFLAMMATION  IN  WOMEN 

in  the  Fowler  position,  as  rest  and  postural  drainage  definitely  minimize 
the  danger  of  upward  extension.  In  children  and  nulliparous  women 
care  must  be  exercised  that  no  application  or  examination  be  carried  past 
the  hymen,  for  specific  infection  of  the  vagina  and  cervix  spreads  to  the 
cervix  and  uterus  with  great  virulence.  Separation  of  the  labia  with  the 
fingers  of  the  gloved  hand  exposes  the  inflamed  parts,  and  careful  irriga- 
tion with  solutions  of  normal  saline  or  weak  permanganate  of  potassium, 
will  remove  the  purulent  discharge.  The  irrigation  should  be  repeated 
several  times  daily,  after  which  the  affected  surfaces  should  be  carefully 
dried  and  painted  over  with  a  two  per  cent  solution  of  argentic  nitrate. 
This  should  be  allowed  to  dry.  The  labia  should  be  kept  separated  to 
allow  for  free  drainage;  this  is  accomplished  by  placing  a  pledget  of  cot- 
ton or  antiseptic  lint  saturated  with  20  per  cent  argyrol  solution  against 
the  urethral  meatus  between  the  swollen  vulvar  lips.  After  a  few  days, 
by  following  the  above  directions,  the  physician  will  be  rewarded  by  see- 
ing the  discharge  markedly  diminished  and  the  vulvar  swelling  lessened. 
The  bowels  may  be  moved  by  salines ;  enemata  arc  dangerous  in  the 
presence  of  gonorrheal  discharges,  for  gonorrheal  proctitis  is  a  most 
intractable  complication.  The  urine  may  be  rendered  bland  and  non- 
irritating  by  the  copious  exhibition  of  pure  water  and  milk,  and  by  the  ad- 
ministration of  full  doses  of  urotropin,  or  of  urotropin  with  benzoate  of 
soda.  The  patient  should  remain  in  bed  while  there  is  pain  and  bladder 
irritability;  also  for  the  space  of,  and  for  some  days  after,  the  menstrual 
period,  as  it  is  during  this  time  that  upward  extension  is  most  likely 
to  occur.    Autogenous  vaccines  seem  to  have  some  curative  value. 

Follicular  Vulvitis. — In  follicular  vulvitis  the  inflammation  is  limited 
to  the  hair  follicles  and  sebaceous  glands  about  the  vulva.  Small  red 
papules  are  scattered  over  the  labia,  and  these  become  pustules  with  a 
hair  in  the  apex  of  each.  The  surrounding  tissues  may  be  unaffected 
or  may  become  more  or  less  inflamed  from  the  confluence  of  the  lesions. 

Irritating  discharges,  lack  of  cleanliness,  parasites,  and  local  irrita- 
tion are  the  chief  predisposing  causes.  The  staphylococcus  albus  is 
the  direct  cause  of  the  pustular  formation;  occasionally  the  condition 
occurs  during  pregnancy. 

Symptoms. — The  symptoms  are  the  same  as  have  already  been  de- 
scribed under  simple  vulvitis. 

Treatment. — The  vulvar  hair  should  be  clipped,  and  the  vulvar  sur- 
faces carefully  cleansed  with  Synol  soap  and  water,  rinsed  with  warm 
water  and  dried.  The  hairs  in  each  pustule  may  be  extracted  with  suitable 
forceps,  and  compresses  saturated  with  alcohol  50  per  cent,  and  boric 
acid  solution,  applied,     Greater  effect  may  be   obtained   by  covering 


INFECTIONS  OF  THE  VULVA,  VAGINA  AND  CERVIX  9 

the  compresses  with  rubber  tissue,  which  in  turn  is  held  in  place  with  a 
T-bandage.  The  compress  should  be  changed  frequently.  Rest  in  bed 
contributes  to  speedy  recovery.  When  the  pustules  are  few  in  number, 
after  the  hairs  have  been  removed  from  each  pustule,  they  may  be  painted 
with  the  tincture  of  iodin,  which  is  allowed  to  dry,  and  the  vulvar  sur- 
faces left  uncovered. 

Diabetic  Vulvitis. — Diabetic  vulvitis  is  caused  by  the  decomposition 
of  diabetic  sugar  loaded  urine  passing  over  the  vulvar  surfaces,  which 
produces  a  dermatitis.  The  tissues  of  the  vulva  and  inner  surfaces  of 
the  thighs  are  of  a  reddish  copper  color  and  the  skin  is  parchment-like, 
corrugated  and  dry  with  moist  areas  in  the  folds  of  the  groin.  The 
itching  is  constant  and  there  may  be  local  pain  and  tenderness.  Eczema- 
tous  changes  frequently  take  place  in  the  skin.  The  patient  is  generally 
poof  in  health  from  the  diabetes  and  her  disturbed  rest. 

Treatment. — The  treatment  is  both  general  and  local;  the  general 
management  consists  in  a  regulated  diet  and  the  adminstration  of  large 
doses  of  bicarbonate  of  soda.  Locally  alkaline  vaginal  douches  always 
give  the  patient  comfort.  The  pruritus  may  be  relieved  by  ointments  or 
dusting  powders  after  the  parts  have  been  carefully  cleansed  with  soap 
and  water  and  the  skin  dried  with  absorbent  cotton.  An  ointment  such 
as  the  following  may  be  applied  and  has  given  much  relief : 

Ac.  salicylici gi"-  x 

Ungt.  petrolati §  j 

Or  a  skin  protective  of  the  following  may  be  used: 

Zinci  stearati 3  iss 

Ac.  carbolici gr.  v. 

Glycerini    o  iss 

Pulv.  tragacan gr.  xij 

Aquae §j 

Dusting  powders  of  stearate  of  zinc  and  cornstarch  blown  on  the  surface 
may  relieve  the  itching.  Excoriations  or  abrasions  of  the  skin  should 
be  painted  with  silver  nitrate,  gr.  xx-§  i,  and  then  covered  with  oint- 
ment. 

INFLAMMATION  OF  THE  VAGINA 

Vaginitis  or  colpitis  is  an  inflammation  of  the  vaginal  mucosa :  it  may 
be  acute  or  chronic^  although  it  occurs  most  frequently  in  the  latter  form.. 


10  PELVIC  INFLAMMATION  IN  WOMEN 

The  histologic  structure  of  the  vaginal  mucosa,  covered  as  it  is  with  sev- 
eral layers  of  pavement  epithelium,  together  with  the  secretions  found 
in  the  vagina,  offers  considerable  resistance  to  bacterial  invasion.  The 
absence  of  vaginal  glands  further  contributes  to  this  resistance  of  the 
vaginal  mucosa  to  the  invasion  of  infecting  bacteria.  In  the  non-preg- 
nant condition  the  vagina  is  kept  moist  by  the  secretions  from  the  uterus 
and  the  cervix;  but  in  pregnancy,  owing  to  the  increase  in  the  pelvic 
circulation,  the  secretion  is  markedly  increased.  These  secretions  are 
bactericidal  in  their  action,  as  has  been  shown  by  both  Doderlein  and 
Williams.  Hence  it  is  difficult  for  pyogenic  organisms,  which  may  gain 
entrance  into  the  vagina,  to  live  therein  and  cause  inflammatory  changes, 
unless  the  natural  vaginal  secretion  is  modified  in  character,  or  the  resist- 
ing lining  of  pavement  epithelium  is  impaired  by  trauma,  thus  dimin- 
ishing the  tissue  resistance.  Yet  under  certain  conditions,  the  germicidal 
action  of  the  vaginal  secretion  may  be  impaired  or  the  development  of 
pyococci  increased,  and  thus  an  infection  of  the  mucosa  occurs. 

In  childhood  or  old  age,  or  when  the  secretions  from  the  cervix  or 
uterus  are  increased  and  changed  in  character — as  is  the  case  at  or  near 
the  menstrual  period,  after  labor,  or  abortion,  or  when  the  uterus  is 
prolapsed — the  vaginal  resistance  is  impaired :  furthermore,  when  the 
vulvovaginal  orifice  is  relaxed,  the  A^agina  becomes  more  sensitive  to 
bacterial  invasion.  While  vulvitis  frequently  occurs  alone,  vaginitis  is 
usually  complicated  with  vulvitis.  There  are  four  clinical  varieties  of 
vaginitis:  (i)  simple  vaginitis,  (2)  gonorrheal  or  specific  vaginitis, 
(3)  granular  vaginitis,  (4)  senile  vaginitis.  Occasionally,  as  a  com- 
plication of  the  exanthemata,  we  may  see  diphtheritic  vaginitis.  In  the 
chronic  form  it  usually  occurs  in  patches ;  it  is  seldom  that  the  entire 
vaginal  mucous  membrane  is  involved. 

Causes. — The  causes  are  both  predisposing  and  exciting.  Under 
the  former  we  may  include  anything  which  impairs  the  local  resistance  of 
the  vagina  to  infection,  such  as  mechanical  or  chemical  irritation,  youth, 
old  age,  feeble  health,  and  such  local  and  systematic  conditions  as  may 
result  in  the  desquamation  of  the  vaginal  epithelium.  Tlie  exciting 
causes  are  bacterial ,  the  gonococcus,  the  streptococcus,  the  staphylococ- 
cus, bacillus  diphtheriae,  and  the  colon  bacillus  being  the  chief  etiological 
offenders. 

The  gonococcus  of  Neisser  is  especially  active  in  the  causation  of  the 
vulvovaginitis  found  in  children.  In  the  exanthemata,  the  vaginal  mu- 
cosa participates  in  the  general  inflammatory  involvement  of  the  mucous 
membranes,  while  in  puerperal  vaginitis,  the  streptococcus  and  the 
pyogenic  bacteria  play  an  active  part  in  the  causation.     Simple  non- 


INFECTIONS  OF  THE  VULVA,  VAGINA  AND  CERVIX  ii 

Specific  vaginitis  is  commonly  the  result  of  irritating  discharges,  cau- 
terants,  and  mechanical   irritants. 

Symptoms. — The  symptoms  of  acute  vaginitis  vary  with  the  severity 
oi  the  involvement.  There  is  commonly  a  feeling  of  heat  and  pain  in  the 
vagina,  which  may  be  dull  or  intense  in  character,  a  throbbing  sensation 
in  the  perineum,  backache,  and  a  slight  elevation  in  temperature  at  first. 
The  vaginal  mucosa  is  hot  and  dry,  for  the  normal  vaginal  secretion  is 
diminished;  but  in  from  twenty-four  to  forty-eight  hours  the  vaginal 
mucosa  becomes  bathed  in  a  thin,  white  mucous  discharge,  which  soon 
becomes  mucopurulent  in  character  and  runs  over  the  external  geni- 
tals. This  causes  intense  vulvar  irritation,  frequently  resulting  in  pruri- 
tus. The  local  symptoms  are  always  more  pronounced  at  the  time  of  the 
menstrual  period.  On  inspection  the  vaginal  walls  are  red,  swollen,  and 
sensitive,  and  are  bathed  in  a  profuse  purulent  discharge;  though  as  a 
rule  the  entire  vaginal  surface  is  not  involved,  the  inflammation  occurring 
in  patches,  separated  from  each  other  by  healthy  tissue.  There  are 
usually  no  urinary  symptoms  in  simple  vaginitis;  this,  however.  Is  not 
true  in  the  gonorrheal  type. 

Gonorrheal  Vaginitis. — In  the  acute  gonorrheal  form  a  history  of 
a  suspicious  intercourse  is  always  suggestive ;  furthermore,  the  symptoms 
are  more  Intense,  while  the  discharge  is  more  profuse,  and  of  a  purulent 
character,  yellowish  or  greenish  in  appearance,  and  of  a  faintly  acid 
or  neutral  reaction.  No  positive  diagnosis  should  be  made  unless  the 
gonococcus  can  he  demonstrated  microscopically.  The  urethra  and  the 
urethral  glands  are  usually  involved,  so  that  frequent  and  burning  urina- 
tion Is  the  rule.  Gonorrhea  of  the  vagina  is  usually  secondary  to  an 
infection  beginning  elsewhere.  On  inspection,  after  wiping  away  the 
pus  from  the  vestibule,  fresh  pus  may  be  expressed  from  the  ducts  of 
Skene's  and  Bartholin's  glands.  The  vaginal  mucosal  membrane  is  dark, 
red  or  bluish  In  color,  Is  more  or  less  thickened  and  studded  with  patches 
of  erosion  which  bleed  easily  on  contact.  Moist  vegetation  may  appeal 
about  the  vulva,  secreting  a  seropurulent  fetid  discharge. 

In  the  chronic  form  there  may  be  few  or  no  symptoms,  except  vulva 
irritation  and  dyspareunia,  due  to  the  mucous  discharge  which  excites 
some  inflammatory  reaction  in  the  tissues  about  the  introitus.  Exacer- 
bations may  occur  near  the  menstrual  period  when  the  gonococcus  rap- 
idly develops  in  the  culture  medium  offered  by  the  menstrual  blood,  and 
may  be  demonstrated  in  the  discharges. 

Granular  Vaginitis. — Granular  or  papillary  vaginitis  is  usually  sub- 
acute or  chronic;  the  granulations  may  result  from  gonorrheal  infection, 
or  from  the  congestion  due  to  pregnancy.     The  papillae  of  the  vagina 


12  PELVIC  INFLAMMATION  IN  WOMEN 

swell  and  become  infiltrated  with  small  cells,  giving  the  mucous  mem- 
brane a  granular  appearance.  The  granulations  are  hemispheric  in  shape, 
small  in  size,  and  scattered  over  the  upper  surface  of  the  vagina  and  the 
cen'ix.  The  granular  vagina  and  cervix  of  the  pregnant  woman  is  of 
common  occurrence,  especially  in  brunettes;  it  is  seldom  however 
associated  with  simple  vaginitis. 

Symptoms. — The  symptoms  are  usually  not  severe;  there  is  a  sense 
of  fullness  and  pressure  in  the  vagina,  and  a  sero-  or  mucopurulent  dis- 
charge which,  as  it  escapes  over  the  external  genitals,  causes  a  vulvar 
pruritus.  Exanthematous  patches  on  the  vulva  are  frequently  present  in 
this  form  of  vaginal  inflammation,  while  small  areas  of  granulations 
are  scattered  over  the  vagina  and  cervix. 

Senile  Vaginitis. — Senile  vaginitis  or  adhesive  vaginitis  is  usually 
found  in  women  past  the  menopause.  It  is  characterized  by  the  formation 
of  adhesions  due  to  the  atrophic  changes  of  old  age,  which  result  in  de- 
fective nutrition  and  local  destruction  of  the  protective  epithelium;  this 
leads  to  infection  and  superficial  ulceration.  Hence,  those  portions  of 
the  vaginal  wall  which  come  in  contact  with  each  other  after  the  epithelial 
covering  has  been  destroyed  are  apt  to  become  adherent. 

Symptoms. — The  symptoms  which  cause  the  patient  to  seek  medical 
advice  are  a  thin,  serous,  acrid,  vaginal  discharge,  which  is  seldom  pro- 
fuse, but  is  frequently  blood  stained;  and  a  burning  sensation  in  the 
vagina,  or  a  feeling  of  weight  in  the  pelvis,  or  marked  irritation,  such  as 
a  pruritus  or  dermatitis  of  the  external  genitals.  The  marital  relations 
may  be  painful  or  impossible,  owing  to  the  atrophic  changes  in  the 
introitus  and  in  the  vaginal  walls.  On  inspection  the  mucous  membrane 
is  found  smooth,  while  various  sized  ecchymotic  spots  and  superficial 
ulcerations  are  seen  scattered  over  its  mucous  surface,  which  is  moistened 
with  a  scanty  serous  secretion.  Digital  exploration  may  detect  adhesions 
between  the  cervix  and  the  vagina  or  between  the  opposing  vaginal  walls. 

Prognosis  of  Vaginitis. — The  prognosis  of  simple  vaginitis  is  usu- 
ally good  when  proper  treatment  is  instituted.  In  the  gonorrheal  variety 
the  prognosis  is  fair  as  to  the  immediate  condition,  but  must  always  be 
guarded,  for  the  infection  may  remain  latent  and  becom.e  active  at  some 
later  date.  Under  favorable  circumstances  it  has  a  tendency  to  extend 
to  the  endometrium,  tubes,  ovaries,  and  pelvic  peritoneum.  Chronic 
vaginitis  is  often  intractable,  recurring  from  time  to  time  with  intense 
pruritus.  In  the  diphtheritic  cases  and  those  due  to  active  cauterants  or 
irritants  (as  an  ill  fitting  pessary)  atresia  of  the  vaginal  tube  may  result 
from  sloughing  of  the  mucosa  and  adhesions  of  the  opposing  walls,  or 
occlusion  of  the  vagina  may  ensue  from  cicatricial  contraction.     In  the 


INFECTIONS  OF  THE  VULVA,  VAGINA  AND  CERVIX  13 

granular  form  the  condition  often  disappears  spontaneously  at  the  end  of 
gestation,  although,  when  of  gonorrheal  origin,  granulations  may  be 
found  in  the  vaginal  vault  years  after  the  original  infection  has  been 
cured.  Senile  cases  are  usually  intractable  and  can  be  made  comfortable 
only  by  persistent  and  frequently  repeated  treatment. 

Treatment. — The  treatment  in  acute  vaginitis  should  include :  ( i ) 
rest  in  bed  and  posture,  (2)  cleanliness,  (3)  relief  of  pain,  (4)  dietary 
regulation.  Rest  in  bed  is  essential  during  the  acute  stage,  even  in  mild 
cases,  and  postural  drainage  favors  local  tissue  recovery.  The  bowels 
may  be  regulated  with  saline  laxatives,  or  laxative  waters.  An  alkaline, 
salt  free,  or  non-stimulating  diet  contributes  to  a  happy  termination. 
Codein,  ^  to  i  gr.  repeated  every  three  to  six  hours,  may  be  used  to 
relieve  the  pain.  Any  posture  that  is  comfortable  to  the  patient  and 
insures  free  vaginal  drainage  is  permissible.  Cleanliness  is  insured  not 
only  by  proper  drainage,  but  by  the  use  of  copious  saline  irrigation  given 
several  times  a  day  with  the  douche  can  or  bag  at  low  elevation. 

In  the  subacute  condition,  silver  nitrate  in  two  per  cent  solution  can 
be  used  to  advantage.  Warm  Fuller's  earth  may  be  packed  in  the 
vagina  through  a  Ferguson  speculum  and  held  in  contact  with  the  in- 
flamed surface  by  a  wool  tampon ;  this  should  be  removed  in  twenty-four 
hours  and  a  cleansing  douche  given. 

In  the  acute  gonorrheal  variety  the  general  principle  of  rest,  posture 
and  cleanliness,  and  dietary  restrictions  as  previously  outlined  should  be 
carried  out.  One  change  however  is  to  be  observed :  no  douches  or  irri- 
gations should  be  given  during  the  acute  stage.  If  more  active  treat- 
ment is  desired,  argyrol  10-25  per  cent  solution  may  be  used;  this  is  best 
applied  in  the  following  manner :  with  the  patient  in  the  dorsal  position 
and  the  hips  well  elevated,  the  labia  are  carefully  separated,  and  from  a 
feeding  cup  the  argyrol  solution  is  poured  into  the  vagina.  The  amount 
to  be  used  should  be  sufficient  to  insure  moderate  distension,  reaching 
all  parts  of  the  vagina.  The  patient  is  then  returned  to  the  Fowler  posi- 
tion and  the  fluid  allowed  to  escape.  Care  should  be  taken  that  proper 
pads  are  placed  under  the  patient  to  absorb  the  excess  of  argyrol. 

Once  the  acute  stage  has  passed,  more  active  treatment  may  be  insti- 
tuted in  the  form  of  potassium  permanganate  douches,  i  14000,  and  the 
topical  application  of  argyrol,  25  per  cent,  and  silver  nitrate,  2-4  per 
cent,  to  the  entire  vaginal  surface. 

Treatment  of  Senile  Vaginitis. — Senile  vaginitis  is  frequently 
but  a  local  manifestation  of  the  atrophic  changes  which  take  place  in 
women  in  the  postclimacteric  period.  To  how  great  an  extent  the  endo- 
crine glands  enter  into  the  etiology  of  this  condition  is  hard  to  say,  but 


14  PELVIC  INFLAMMATION  IN  WOMEN 

unquestionably  they  play  a  part.  Clinically  ovarian  extract  in  doses  of 
2-5  grains  three  times  a  day  often  seems  to  help.  The  use  of  other  endo- 
crines,  of  course,  depends  largely  on  the  patient's  general  condition,  and 
this  must  be  determined  by  the  physician  in  attendance.  There  is  no 
question  that  better  results  are  obtained  by  the  routine  use  of  ovarian  and 
thyroid  extracts  in  combination  with  local  measures,  than  by  topical 
applications  alone.  These  patients  should  be  encouraged  in  the  liberal 
use  of  alkalies,  such  as  the  internal  administration  of  sodium  and  mag- 
nesia carbonate,  while  the  topical  application  of  silver  nitrate,  in  strengths 
of  2-10  per  cent,  is  often  of  assistance. 

ENDOCERVICITIS 

Endocervicitis  is  an  inflammation  of  the  intracervical  mucous  mem- 
brane, and  may  be  either  an  acute  or  chronic,  and  may  occur  either  as  a 
primary  or  secondary  infection.  It  is  primary  when  the  infecting  agent 
directly  invades  the  cervical  mucosa,  and  secondary  when  the  infection 
extends  upward  from  the  vagina  or  downward  through  the  uterus. 

Acute  Endocervicitis. — The  acute  form  is  due  to  direct  invasion  of 
the  mucosa  by  septic  or  specific  bacteria.  When  of  septic  origin,  cervicitis 
is  but  a  part  of  the  general  infection  of  the  uterovaginal  tract.  It  never 
occurs  as  a  pathologic  entity.  On  the  other  hand,  the  gonococcus  may 
cause  an  acute  primary  endocervicitis  without  involving  the  adjacent 
tissues,  or  be  checked  at  the  internal  os  and  the  inflammation  pass  into 
the  subacute  or  chronic  stage,  involving  the  glandular  crypts  of  the 
cervix  and  producing  a  chronic  glandular  cervicitis.  The  infection  may 
remain  latent  for  long  periods,  unless  it  is  carried  on  into  the  uterus  by 
meddlesome  instrumentation.  Furthermore,  because  of  the  anatomic 
relations  of  the  cervix,  it  must  necessarily  participate  in  the  acute  in- 
fections of  the  uterus  and  the  vagina;  hence,  acute  cervicitis  need  not  be 
considered  clinically  as  a  pathologic  entity,  for  both  its  symptomatology 
and  treatment  are  those  of  the  associated  lesions. 

Chronic  Endocervicitis. — Chronic  endocervicitis  is  a  low  grade  in- 
flammation of  the  cervical  mucosa.  Thii>  inflammatory  process  may 
be  confined  to  the  mucosa  of  the  cervical  canal,  or  may  extend  into  the 
deeper  tissues  of  the  cervix,  producing  a  cervicitis. 

Endocervicitis  is  the  most  prevalent  of  all  gynecological  disorders. 
Fully  85  per  cent  of  all  women,  single  or  married,  have  infected  cervices. 
It  is  the  same  condition  described  as  "cervical  erosion,  cervical  catarrh, 
or  cervical  endometritis"  by  the  older  writers,  but  strange  to  say,  they  did 
not  understand  the  pathology  and  wholly  failed  to  appreciate  the  infec- 
tive origin  of  the  disease,     Their  methods  of  treatment  therefore,  as 


INFECTIONS  OF  THE  VULVA,  VAGINA  AND  CERVIX 


IS 


might  be  expected,  were  palliative  and  not  curative,  hence  in  the  ma- 
jority of  instances  were  tedious  and  unsuccessful. 

In  both  structure  and  function,  the  cervical  mucosa  differs  widely 
from  the  mucosa  of  the  corpus  uteri.  The  cervical  canal,  lined  with  its 
mucosa,  simply  acts  as  a  passive  communicating  channel  between  the 
vagina,  which  is  always  the  habitat  of  many  and  various  bacteria,  and 
the  uterine  cavity.  On  the 
other  hand,  the  corporeal  en- 
dometrium is  constantly  pass- 
ing through  such  active 
changes  as  are  essential  to  the 
function  of  menstruation  and 
deciduation.  The  cervical 
mucosa  contains  large  num- 
bers of  deep,  penetrating  race- 
mose glands  and  evinces  a 
marked  susceptibility  to  infec- 
tion; while,  according  to  Cur- 
tis, the  normal  corporeal  mu- 
cosa is  practically  immune  to 
infection. 

Etiology.  —  The  organ- 
isms most  commonly  found  to 
be  the  infecting  agents  in  en- 
docervicitis  are  the  gonococ- 
cus,  staphylococcus,  strepto- 
coccus and  colon  bacillus.  The 
gonocbccus  and  the  staphylo- 
coccus are  by  far  the  most 
prevalent.  Trauma,  lacerations 
during  childbirth  or  the  result 
of  instrumental  delivery,  cau- 
terization, or  the  constant  irritation  of  a  stem  pessary,  may  open  up 
avenues  of  entrance  for  infection,  and  are  thus  predisposing  factors  in 
the  production  of  chronic  cervical  inflammation.  But  trauma  is  only 
a  contributory  cause,  for  as  Sturmdorf  so  aptly  says,  "the  dominating 
pathologic  factor  that  determines  the  morbidity  of  a  cervical  laceration 
is  not  the  extent  of  the  tear,  but  the  incidence  of  its  infection.  Such 
an  infection  does  not  remain  limited  to  the  lacerated  area,  but  sooner 
or  later  involves  the  entire  endocervical  mucosa  and  the  subjacent  tissue 
from  the  internal  os." 


Fig.  3. — Cystic  Cervicitis  Resulting  from  In- 
fection OF  A  Cervix  Laceration. 


i6  PELVIC  INFLAMMATION  IN  WOMEN 

In  children,  vulvovaginitis  or  the  exanthemata,  particularly  diphtheria 
and  scarlet  fever,  and  the  general  debilitating  diseases  may  produce  in  the 
cervix  a  lowered  tissue  resistance,  increasing  its  susceptibility  to  mixed 
infections.  Hess  says  that  "we  must  regard  the  average  gonorrheal  vul- 
vovaginitis in  children  as  involving  the  cervix  rather  than  the  vagina, 
and  must  consider  the  infection  as  a  cervicitis  rather  than  a  vaginitis." 

As  we  have  already  stated,  acute  endocervicitis  and  cervicitis  occur 
in  the  course  of  acute  gonorrheal  and  puerperal  infections  of  the  uterus, 
but  are  seldom  recognized  as  definite  pathological  entities,  as  their  symp- 
tomatology is  masked  by  the  more  extensive  lesion  in  the  uterus. 

Pathology. — The  mucosa  of  the  cervix,  when  it  is  a  seat  of  chronic 
infection,  becomes  swollen  and  everted,  while  the  mucosa  of  the  portio 
about  the  external  os  presents  a  circumscribed  area  of  glandular  prolifer- 
ation. The  columnar  epithelium  covering  the  mucosa  of  the  cervical 
canal,  under  the  constant  stimulation  of  infection,  rapidly  proliferates 
and  actually  pushes  itself  out  on  the  vaginal  aspect  of  the  cervical  rim, 
replacing  the  stratified  epithelium  which  is  normally  present  in  this 
situation,  producing  the  so-called  erosion.  This  erosion  or  "red  area" 
about  the  external  os,  therefore,  is  not  ulceration,  hut  is  actually  a  new 
cell  formation,  an  overgrowth  of  lymphoid  tissue,  which  may,  under 
certain  conditions,  become  malignant.  The  continued  congestion  incident 
to  such  a  condition  produces  a  hypersecretion  of  mucus  from  the  gland \ 
structure,  and  a  hypertrophy  and  hyperplasia  of  cervical  connective  tis- 
sue. Sooner  or  later,  owing  to  the  tissue  hyperplasia,  the  crypts  of  the 
cervical  glands  become  occluded  and  the  secretion  is  retained,  thus  form- 
ing retention  cysts,  the  so-called  nabothian  cysts,  so  commonly  found  in 
this  region  of  the  cervix. 

These  cyst  formations  are  produced  partly  by  the  hyperplasia  of  the 
periglandular  connective  tissue,  encroaching  upon  the  lumen  of  the  gland 
duct,  and  partly  by  the  overproduction  of  thick  viscid  mucus  which  may 
plug  the  outlet  ducts  ;  or,  during  the  process  of  cure,  or  even  of  attempted 
healing,  the  squamous  epithelium  may  grow  out  over  the  erosion  and 
actually  "choke"  or  cover  over  the  gland  openings.  This  cystic  condi- 
tion naturally  increases  the  bulk  of  the  already  hypertrophied  cervix 
and  thereby  further  interferes  with  its  circulation  and  muscular  contrac- 
tion. It  is  this  hyperplasia  which  causes,  by  interference  with  the  cervical 
circulation,  the  premenstrual  and  the  postmenstrual  metrorrhagia,  so 
frequently  met  with  in  the  general  cyst  formation  of  the  cervix. 

Microscopically  we  find  the  evidences  of  a  chronic  inflammation,  or 
on  the  other  hand,  there  may  be  very  little  inflammatory  change  in  the 
stroma,  and  except  for  a  preponderance  of  gland  tissue,  the  section  may 


INFECTIONS  OF  THE  VULVA,  VAGINA  AND  CERVIX 


17 


appear  almost  as  normal  cervical  tissue.  Section  of  a  distended  nabothian 
follicle  may  show  as  a  large  clear  space  lined  with  columnar  epithelium 
and  filled  with  mucus.  Surrounding  this,  there  may  be  the  signs  of  a 
subacute  inflammation,  as  shown  by  round  cell  infiltration,  congestion, 
edema,  dilated  lymph  spaces,  etc.  In  the  musculature  nearest  the  cervical 
mucosa  there  may  be  found  small  inflammatory  foci  or  even  small  mul- 
tiple abscess  formations. 

Serial  sections  made  from  the  excised  cones  of  cervical  tissue  similar 
to  those  shown  in  figure  4  show  erosions,  chronic  inflammation,  cystic 
changes,  etc.,  as  described,  in  varying 
degrees  of  intensity.  Beginning  at  the 
distal  or  portial  end,  we  find  marked 
inflammatory  changes,  but  as  we  ap- 
proach the  proximal  extremity,  i.e., 
near  the  internal  os,  these  changes  are 
either  barely  perceptible  or  are  entirely 
absent,  showing  the  efiicacy  of  the  sur- 
gical procedure  to  be  described  under 
treatment,  in  so  far  as  the  removal  of 
the  infected  area  is  concerned. 

Clinical  Course. — The  clinical 
course  of  chronic  endocervicitis  is  slow 
and  insidious  and  shows  little  or  no 
tendency  toward  a  spontaneous  cure 
— the  symptoms  are  variable.     In  the 

milder  cases,  where  the  infection  is  not  sufficiently  virulent  to  be  pro- 
gressive, cervical  leukorrhea  of  a  mucoid  or  mucopurulent  character, 
which  may  be  scanty  or  profuse,  is  the  only  symptom  complained  of; 
very  simple  to  describe,  but  often  extremely  invidious  to  the  patient 
and  well  nigh  invincible  to  the  physician.  When  the  infection  extends 
to  the  deeper  structure  of  the  cervix,  the  uterus  may  become  involved. 
This  is  brought  about  by  an  ascending  lymphangitis  between  the  uterine 
muscle  bundles.  Such  a  condition  naturally  excites  a  tissue  reaction 
with  a  deposition  of  inflammatory  products  between  the  muscle  fibers; 
this  in  turn  interferes  with  the  rhythmic  contraction  of  the  uterine  mus- 
cle fibers,  and  allows  a  resulting  circulatory  stasis,  thus  interfering  with 
drainage  and  favoring  chronic  infection  and  involvement  of  the  para- 
metria! tissues.  The  fallopian  tubes  later  become  involved  through  a 
parametritis;  a  perisalpingitis,  peritonitis,  and  peri-ovaritis  may  result. 
Abdominal  section  on  several  hundred  cases  of  chronic  endocervicitis 
of  long  standing,  has  never  failed  to  show  some  evidence  of  the  ex- 


FiG.  4. — Cone  Taken  from  Infected 
Cervix,  Showing  Points  from 
WHICH  Serial  Sections  Were 
Made. 


i8 


PELVIC  INFLAMMATION  IN  WOMEN 


tension  of  the  infection  to  the  peritubular  structures  and  the  ovaries. 
In  the  presence  of  such  a  circulatory  and  lymphatic  stasis,  the  pelvic 
structures  are  more  susceptible  to  new  infection  and  less  resistant  to 
old  infection. 

Symptoms. — Chronic  endocervicitis  is  ahmys  attended  by  some  de- 
gree of  posterior  celliditis  in  the  nterosacral  ligaments.  This  produces 
the  premenstrual  and  comenstrual  backache  as  well  as  the  dyspareunia 

so  frequently  com- 
plained of;  however, 
the  prominent  symptom 
in  most  cases  is  leukor- 
rhea.  This  discharge 
is  intermenstrual,  is 
mucoid  in  character, 
and  is  usually  profuse 
and  viscid;  it  may  be 
translucent  or  opaque, 
or  curdy,  or  it  may  be 
purulent  when  the  in- 
flammation is  suppura- 
tive. It  is  always  more 
abundant  just  before 
and  after  the  menstrual 
periods.  The  patient 
may  also  suffer  from 
metrorrhagia,  resulting 
from  the  circulatory 
stasis  due  to  the  inter- 
muscular lymphangitis, 
which  has  impaired  the  contractile  power  of  the  uterine  muscle.  The 
lumbosacral  pain  is  due  to  the  traction  of  the  cervix  on  the  thickened 
tender  uterosacral  ligaments.  Some  patients  may  complain  of  no  symp- 
toms, though  a  specidum  examination  will  always  reveal  the  erosion, 
the  cystic  hyperplasia,  and  the  presence  of  a  cervical  discharge. 

Sterility  in  women  with  apparently  normal  cervices,  which  may  or 
may  not  be  anteflexed,  is  in  the  vast  majority  of  cases  due  to  the  exist- 
ence of  a  chronic  endocervidtis,  dating  either  from  childhood  or  from  an 
infection  contracted  soon  after  marriage.  Such  an  infection  need  not  be 
gonorrheal,  for  we  know  that  staphylococci  from  the  husband's  prostate 
gland  are  often  sufficiently  virulent  to  infect  the  cervical  mucosa  of  his 


Fig.   5. — Gross   Appearance  of  Excised   Cone,   Show- 
ing Muscle  Tissue  Replaced  by  Fibrous  Tissue. 


INFECTIONS  OF  THE  VULVA,  VAGINA  AND  CERVIX  19 

wife,  and  produce  an  intractable  endocervicitis,  even  though  his  last 
debauch  was  twenty  years  previous  to  his  marriage. 

Reynolds,  of  Boston,  has  demonstrated  that  a  spermatozoon,  no  mat- 
ter how  vigorous,  cannot  long  withstand  the  strain  of  progress  through 
the  thick  tenacious  mucus  and  clumps  of  pus  cells  that  plug  the  canal  of 
a  diseased  cervix.  Furthermore,  the  cervical  infection  following  upon 
lacerations  of  the  cervix  in  those  women  who  have  borne  one  child, 
but  have  subsequently  remained  barren,  must  be  recognized  as  a  very 
important  factor  in  the  production  of  their  continued  sterility. 

Differential  Diagnosis. — Chronic  endocervicitis  and  cervicitis 
have  to  be  differentiated  from  malignant  disease  of  the  cervix  and  cervi- 
cal tuberculosis.  In  cancer  of  the  portio  vaginalis  in  the  initial  stage 
the  affected  lip  is  nodular  and  indurated.  The  nodules  are  glazed  and 
bluish  white  and  the  mucosa  may  be  unbroken,  or  the  mucosa  may  be 
eroded,  in  which  case  the  eroded  area  is  always  friable,  bleeds  easily 
on  manipulation,  and  the  surrounding  cervical  tissue  is  hard  and  in- 
filtrated. In  chronic  cervical  inflammation,  the  everted  area  is  covered 
with  thick  tenacious  mucus  or  mucopus.  In  cancer  the  secretion  loses 
its  mucoid  character  and  the  erosion  secretes  a  serous,  sero sanguine oits, 
or  sero purulent  discharge.  A  histologic  examination  will  make  the  diag- 
nosis positive. 

Primary  tuberculosis  of  the  cervix  is  very  rare ;  it  may  appear  in  three 
pathological  forms:  (a)  the  ulcerative,  (b)  the  hyperplastic,  (c)  the  mili- 
ary (Beyea).  The  tubercular  ulcer  of  the  cervix  is  sharply  cut,  irregular, 
undermined,  and  usually  commences  near  the  external  os  and  spreads 
over  the  portio  vaginalis  and  up  the  canal.  The  edges  may  be  covered 
with  necrotic  material,  while  the  floor  is  soft  and  there  is  an  absence 
of  induration.  The  base  is  uneven  and  tends  to  heal  by  cicatrization. 
The  diagnosis  is  based  upon  the  microscopical  findings,  which  will  show 
the  presence  of  giant  cells,  tubercles,  and  tubercle  bacilli,  in  and  about 
the  ulcer. 

In  the  hyperplastic  form  the  cervix  is  grossly  enlarged  and  hard, 
simulating  chronic  cervicitis,  and  the  tubercles  are  within  the  muscle 
bundles,  or  surrounded  by  masses  of  protective  connective  tissue  in  the 
stroma. 

Miliary  tuberculosis  of  the  cervix  has  seldom  been  recognized.  The 
miliary  type  of  lesion  is  an  early  stage  of  ulceration;  granulating  tuber- 
cles protrude,  these  may  be  isolated  or  confluent.  A  positive  diagnosis 
can  only  be  made  by  the  aid  of  the  microscope,  the  clinical  history,  and 
in  finding  tuberculosis  elsewhere  in  the  body. 

Syphilitic  ulceration  of  the  cervix  may  occur,  but  it  is  extremely  rare. 


20  PELVIC  INFLAMMATION  IN  WOMEN 

While  a  chancre  of  the  cervix  may  be  found  on  either  the  anterior  or 
the  posterior  lips,  it  may  appear  as  a  single  ulcer,  or  be  multiple.  The 
characteristics  of  chancre  of  the  cervix  do  not  differ  from  those  of 
chancre  in  other  parts  of  the  genital  tract.  The  diagnosis  depends  upon 
the  presence  of  the  characteristic  lesion,  a  positive  Wassermann,  together 
with  other  evidences  of  luetic  infection.  Microscopic  examination  of 
the  diseased  tissue  and  finding  of  spirochetes  will  confirm  the  diagnosis. 

Prognosis. — The  prognosis  in  chronic  endocerzncitis  must  he 
guarded.  When  the  infection  is  slight  and  the  coincident  inflammation 
mild,  and  proper  treatment  is  instituted  early,  complete  recovery  may 
take  place.  On  the  other  hand,  when  the  infection  is  virulent  and  the 
inflammatory  changes  within  the  cervical  tissue  are  marked,  the  cure  is 
difficult,  as  there  are  many  associated  lesions.  The  cervical  glands,  be- 
cause of  their  histologic  structure,  may  harbor  infecting  organisms  for 
years.  These  glands  are  situated  in  a  tissue  that  is  richly  supplied  with 
lymphatic  drainage;  and  these  lymphatic  channels  are  connected  with 
lymph  channels  of  the  uterus,  which  in  turn  communicate  with  lymphatic 
chains  in  the  parametrial  tissues  and  in  the  uterosacral  ligaments.  Hence, 
it  will  be  seen  that  the  associated  lesions,  as  metritis,  parametritis,  and 
uterosacral  cellulitis,  are  progressive,  and  not  until  the  focal  infection  is 
cured,  can  these  associated  lesions  which  actually  produce  the  symptoms 
of  leukorrhea,  menorrhagia,  metrorrhagia,  and  lumbosacral  backache  be 
improved. 

Long  continued  cervical  inflammation  may  be  considered  a  prodrome 
of  cervical  cancer,  for  it  is  but  a  step  from  the  extreme  cell  proliferation 
with  an  orderly  arrangement  that  occurs  in  hyperplastic  endocervicitis 
and  cervicitis,  to  the  disorderly  arrangement  of  embryonal  cells  found  in 
cancer. 

Treatment. — The  treatment  of  chronic  endocervicitis  is  palliative 
or  operative.  In  considering  the  treatment  of  any  infective  process, 
we  should  in  the  usual  course  of  events  consider  first,  the  treatment 
during  the  acute  stage,  and  second,  that  of  the  chronic ;  but  unfortunately 
the  acute  stage  of  endocervicitis  as  a  pathological  entity,  is  seldom  recog- 
nized, and  for  that  reason  the  disease  becomes  subacute  or  chronic,  with 
its  resulting  pathology,  long  before  the  patient  seeks  medical  advice. 

In  acute  endocervicitis  of  gonorrheal  origin  rest,  postural  drainage, 
and  local  cleanliness,  are  the  fundamentals  of  treatment.  Alkaline 
douches  of  warm  borax  or  soda  bicarbonate  solution,  given  at  a  low  ele- 
vation, will  dissolve  and  wash  away  much  of  the  profuse  purulent  or 
mucopurulent  discharge.  Great  care  must  be  exercised  to  avoid  pro- 
ducing any   trauma  and  thus  disturbing   nature's  effort  to  arrest   the 


INFECTIONS  OF  THE  VULVA,  VAGINA  AND  CERVIX 


21 


infective  process  by  tissue  reaction.  The  same  general  principles  of 
rest,  postural  drainage  and  cleanliness  likewise  apply  to  postabortal  and 
puerperal  endocervicitis,  but  here,  however,  the  endocervicitis  is  only  a 
part  of  the  endometrial  infection,  and  as  the  internal  os,  which  in  the 
uterus  is  the  natural  barrier  to  the  upward  extension  of  infection,  is 
never  closed  in  the  acute  stage  of  a  postabortal  endometritis,  direct  local 
measures  should  be  avoided. 

The  palliative  treatment  of  chronic  erosions  of  the  cervix,  as  com- 
monly given  in  office  practice,  is  often  more  harmful  than  beneficial,  for 
the  reason  that  many  practitioners 
do  not  appreciate  the  pathology  or 
the  importance  of  the  incidence  of 
infection  in  treating  these  eroded 
surfaces.  Simple  non-infected  ero- 
sions will  usually  clear  up  with 
improvement  of  the  uterine  circu- 
lation. When  complicated  by  retro- 
version this  may  be  done  by  repo- 
sition of  the  uterus  and  its 
retention  in  the  normal  position 
with  a  properly  fitted  pessary;  and 
a  few  applications  of  Churchill's 
tincture  of  iodin,  or  a  single  ap- 
plication of  pure  carbolic  acid  to 
the  eroded  surface,  made  after  the 
mucus  has  been  removed  by  the 
application  of  a  paste  of  bicar- 
bonate of  soda  mixed  with  peroxid 
of  hydrogen  to  the  mucus  covered 
area.  In  the  non-parous  married 
woman  sexual  abstinence  will  do  much  toward  improvement  of  the 
uterine  circulation  and  thus  favor  healing  of  the  erosions. 

If  these  simple  measures  fail,  the  dry  treatment  suggested  by  Gell- 
horn  and  Curtis  will  frequently  result  in  a  cure,  provided,  however,  the 
deeper  structures  are  not  involved.  This  treatment  consists  in  thor- 
oughly cleansing  the  vagina  and  cervix  with  a  hot  alkaline  douche.  The 
cervix  is  then  exposed  through  a  Ferguson  speculum  and  the  cervical 
canal  and  the  erosion  with  the  least  possible  trauma  is  cleared  of  mucus 
by  the  application  of  peroxid  paste.  After  the  mucus  has  thus  been 
cleared  away,  hot  Fuller's  earth  is  packed  about  the  cervix  and  kept  in 
place  by  filling  the  vagina  with  a  gauze  tampon.     The  gauze  is  removed 


Fig.  6. — Chronic  Endocervicitis  Treated 
BY    Linear   Cauterization. 


22 


PELVIC  INFLAMMATION  IN  WOMEN 


Fig.     7. — Same     Cervix     After     Linear 
Scars   Made  by  Cautery  are  Healed. 


in  twenty- four  hours  and  the  pa- 
tient takes  a  hot  alkaHne  vaginal 
douche.  This  treatment  is  repeated 
every  other  day,  and  in  those  in- 
stances where  the  infection  has 
remained  in  the  superficial  tissues, 
the  erosion  and  leukorrhea  are  in  a 
large  proportion  of  the  cases  cured. 
In  the  more  extensive  erosions 
associated  with  moderate  degrees 
of  cervical  laceration  and  ectropion, 
the  eroded  areas  may  be  healed 
by  linear  -cauterization  after  the 
method  of  Hunner  and  Russell. 
The  technic  of  this  procedure  is  as 
follows :  With  the  patient  in  the 
Sims  position  and  the  cervix  ex- 
posed by  a  Sims  speculum,  the 
anterior  lip  of  the  cervix  is  grasped 
with  double  tenaculum  and  held  in 
position,  while  the  cervical  canal  is  cleared  of  mucus.  The  fine  point  of 
the  actual  cautery  knife,  cold,  is  then 
introduced  into  the  canal  to  a  point 
just  beyond  the  uppermost  limit  of  the 
ectropion.  The  current  is  then  turned 
on  and  a  linear  incision,  going  through 
the  mucosa  into  the  underlying  myo- 
metrium, to  the  depth  of  about  one- 
eighth  to  one-fourth  of  an  inch,  is 
made.  The  cervix  is  then  painted  over 
with  iodin,  and  the  patient  is  told  to 
return  in  two  weeks,  when  another 
similar  incision  is  made  on  the  opposite 
aspect  of  the  canal.  Two  weeks  later 
a  third  incision  is  made  midway  be- 
tween the  first  and  second,  and  finally 
we  make  a  fourth  incision  opposite 
the  third  (Fig.  6).  In  all  four,  linear 
cauterizations    are   made,    and    as   the 

resulting  ulcers  heal  and  the  tissue  retracts,  the  ectropion  disappears, 
provided  the  treatment  has  been  successful.    There  is  at  least  one  valid 


Fig.  8. — Twenty-five  Milligrams  op 
Radium  in  a  Brass  Filter  Placed 
in  the  Cervix. 


INFECTIONS  OF  THE  VULVA,  VAGINA  AND  CERVIX  23 

objection  to  the  employment  of  this  treatment,  and  that  is,  that  by  the 
time  this  treatment  is  instituted,  many  of  the  cervical  glands  have  already 
become  infected  and  the  resuking  linear  cicatrix  may  plug  the  lumena 
of  the  ducts  and  leave  infected  glands  buried  in  the  deeper  structures, 
which  may  later  form  cysts. 

Another  form  of  treatment  that  has  been  recommended  is  the  thor- 
ough curettage  of  the  cervical  canal  and  that  part  of  the  everted  mucous 


Fig.  9. 


-Tenacula  on  the  Anterior  and  Posterior  Lips  of  the  Cervix  within  the 
Margin  of  the  Erosion. 


membrane  surrounding  the  external  os  with  a  specially  devised  small, 
sharp  curet.  This  method,  we  believe,  is  open  to  the  same  criticism  as 
the  Hunner  cauterization  method.  Curettage  can  never  remove  all  the 
gland  tissue  of  the  cervical  mucosa,  and  wherever  the  gland  tissue  re- 
mains undisturbed,  the  infection  remains  unmolested.  The  infecting  or- 
ganisms inhabit  the  most  remote  branches  of  the  deepest  glands  in  the 
cervical  mucosa,  and  therefore,  the  futility  of  eradicating  all  the  infective 
foci  by  curettage  is  at  once  apparent. 

After  giving  all  these  methods  a  fair  trial,  we  feel  that,  aside  from 


24 


PELVIC  INFLAMMATION  IN  WOMEN 


the  simple  erosions  of  limited  area  which  are  not  infected,  palliative 
treatment  does  not  cure  endocervicitis. 

Recently,  at  the  suggestion  of  Curtis,  we  have  used  radium  for  the 
cure  of  leukorrhea  and  cervical  erosion,  when  the  bulk  of  the  cervix  has 
been  increased  by  tissue  hyperplasia.  With  the  cervix  exposed  and 
cleared  of  mucus,  a  capsule  containing  25  milligrams  of  radium  en- 
closed in  the  proper  filter  is  introduced  into  the  cervical  canal,  and  held 


Fig.  10. — The  Same  Procedure  May  Be  Used  in  Infected  Lacerations. 


in  place  with  a  very  narrow  gauze  packing,  or  by  placing  a  stitch  in  the 
portio  which  passes  through  both  lips  and  the  ring  of  the  capsule  (Fig. 
8).  The  application  is  kept  in  the  cervix  for  eight  hours  and  then  re- 
moved. Within  a  few  weeks  the  erosion  is  healed,  the  leukorrhea  is 
checked,  and  the  bulk  of  the  cervix  materially  reduced.  Our  experience, 
however,  is  too  limited  for  us  to  draw  any  definite  conclusions,  except 
to  advise  its  further  trial. 

Operative  Treatment. — Sturmdorf,  in  his  very  excellent  work,  has 
called  attention  to  the  pathology  resulting  from  chronic  endocervicitis, 


Fig.  II. — Incision  Circling  the  Limits  of  the  Erosion. 


Fig.  12.— The  Portial  Mucosa  Is  Then  Pushed  Back  to  Make  the  Cuff. 

25 


26 


PELVIC  INFLAMMATION  IN  WOMEN 


and  has  suggested  excision  of  the  infected  area  by  a  method  which  pre- 
serves the  greater  part  of  the  cervical  musculature. 

During  the  past  three  years,  at  the  Long  Island  College  Hospital,  we 
have  treated  all  cases  of  extensive  chronic  endocervicitis  with  the  asso- 
ciated tissue  hyperplasia  already  described,  which  have  not  yielded  to 
some  of  the  palliative  measures,  by  the  surgical  method  of  Sturmdorf. 


Fig.    13. — With    Sharp   Pointed   Emmet's    Scissors   the   Glandular   Portion   of 

THE  Cervix  Is  Coned  Out. 


The  technic  of  this  procedure  with  certain  modifications  which  we  be- 
lieve are  advantageous,  may  be  descril:)ed  as  follows : 

\\'ith  the  patient  anesthetized  and  placed  in  the  lithotomy  position, 
and  the  vulva,  vagina,  and  cervix  prepared  for  operation,  the  anterior 
and  posterior  lips  of  the  cervix  within  the  margin  of  the  erosion  are 
grasped  with  Jacob's  forceps  and  the  cervix  pulled  down.  An  incision 
is  then  made  through  the  mucous  membrane  of  the  portio  vaginalis 
encircling  the  limits  of  the  eroded  area  (Fig.  11).  The  portial  mucosa 
is  now  pushed  back  for  a  distance  of  three  fourths  of  a  centimeter,  or 
more  if  necessary,  to  secure  a  sufficient  cuff  of  the  portial  mucous  mem- 


INFECTIONS  OF  THE  VULVA,  VAGINA  AND  CERVIX 


27 


brane  to  completely  cover  over  the  excised  area  of  cervical  tissue  (Fig. 
12),  Then,  with  a  sharp  pointed  pair  of  Emmet's  scissors,  w^hile  trac- 
tion is  being  made  on  the  cervix,  the  entire  granular  area  surrounding 
the  cervical  canal  is  "coned  out."  The  conical  excision  should  extend 
up  to  or  just  below  the  internal  os  (Fig.  13).  Great  care  must  be  ex- 
ercised to  preserve  as  much  as  possible  of  the  muscle  tissue,  and  still 
to  remove  all  of  the  infected  area.    If  too  much  cervical  tissue  is  removed, 


Fig.  14. — A  Single  Tenaculum  Is  Introduced  into  the  Uterine  Canal  and  the  Two 
Catgut  Sutures  Are  Held  Taut.  This  Brings  the  Uterus  Down  Nearer  the  Vulva. 


the  operation  becomes  a  hi^h  amputation,  which  for  obvious  reasons 
should  be  avoided.  If,  on  the  other  hand,  not  enough  tissue  is  removed, 
infected  glands  are  left  behind  and  the  purpose  of  the  whole  operation  is 
defeated.  By  keeping  well  within  the  muscle  rim,  the  hemorrhage  is 
inconsiderable,  as  the  blood  supply  is  distal  to  the  line  of  excision. 

Before  removing  the  conical  plug  which  is  now  attached  by  only  a 
small  rim  of  cervix  tissue  and  cervical  mucosa,  two  sutures  of  no.  2 
chromic  catgut  on  a  full  curved  cervical  needle  are  placed  through  the 
previously  liberated  flap  of  vaginal  mucous  membrane,  to  either  side 


28 


PELVIC  INFLAMMATION  IN  WOMEN 


of  the  partially  excised  cone.    Each  suture  should  include  a  good  bite  of 
cervical  tissue    (Fig.    14).      When   these   sutures   are   drawn   taut,   the 


Fig.  15. — Sagittal  Section  of  the  Inverting  Stitch. 


operative  field  is  brought  well  down  toward  the  vulva.    The  cervical  canal 
at  the  utmost  limit  of  the  cone  is  now  opened  and  a  single  tenaculum  is 

introduced  into  the  canal  (Fig.  14) 
for  the  purpose  of  further  bringing 
the  cervical  stump  down  nearer  the 
vulva.  When  this  is  done  the  re- 
mainder of  the  cone  is  excised.  The 
vaginal  flap  originally  liberated  at  the 
beginning  of  the  operation  is  now  in- 
verted into  the  hollowed  out  shell  of 
the  cervix  by  the  double  inverting 
stitch  of  Sturmdorf.  This  maneuver 
brings  the  cuff  of  vaginal  mucosa  into 
contact  with  the  cervical  mucosa  and 
thus  completely  covers  all  the  denuded 
areas,  and  furthermore,  substitutes 
healthy  vaginal  mucosa  as  a  lining  to 
the  canal  for  the  infected  cervical 
mucosa  which  has  been  removed. 
This  stitch  is  of  silkworm  gut  and, 
when  tied,  not  only  coaptates  the  vaginal  mucosa  to  the  cervical  mucosa, 
but  controls  bleeding  from  the  tissues  through  which  it  passes    (Fig. 


Fig.  16. — When  This  Is  Drawn 
Taut  the  Portial  Mucosa  Is  in 
Contact  with  the  Mucosa  of 
THE  Canal. 


INFECTIONS  OF  THE  VULVA,  VAGINA  AND  CERVIX 


29 


HP 

, /^ 

[K4- 

y 

\M 

s 

1 

n 

m 

^9^^V  ■ 

B 

1 

^r^^^^'     ''*' ' 

)  taHM 

am 

1 

/ 

m 

Fig.  17. — A  Silkworm  Gut  Stitch  Is  Next  Passed,  as   per   Diagram,   Through 

THE    PORTIAL     MUCOSA    AND    INTO    THE    CanAL. 

17).  This  suture  is  left  in  situ  for  three  or  four  weeks,  or  until  the 
patient  returns  for  her  follow  up  examination,  after  her  discharge  from 
the  hospital.  The  chromic  gut  sutures 
to  either  side,  which  have  thus  far  acted 
as  traction  sutures,  are  now  tied,  bring- 
ing the  gaping  outer  angles  of  the  "coned 
incision"  together,  and  completely  con- 
trolling hemorrhage.  With  all  sutures 
tied,  six  in  number  (Fig.  18),  the  opera- 
tion is  complete,  and  a  small  strip  of 
iodoform  gauze  drain  is  placed  against 
the  cervical  stump,  which  is  removed  in 
twenty-four  hours. 

Objection    has    been    raised    to    this 
procedure  on  the  ground  that  it  is  too 
extensive  for  such  a  simple  lesion,  and  that  it  may  cause  cervical  dystocia 
during  dilatation  in  subsequent  labors.     We  have  done  this  operation 


Fig.  18. — When  All  Stitches 
Are  Tied  the  Erosion  Is  Re- 
placed with  Vaginal  Mucosa. 


30  '  PELVIC  INFLAMMATION  IN  WOMEN 

for  a  sufficient  time  to  form  some  definite  conclusions  as  to  its  value. 
In  the  first  place,  it  cures  the  leukorrhea  and  hence  improves  the  proba- 
bility of  conception;  second,  a  tracheloplasty  of  this  type  does  not 
interfere  with  normal  dilatation  during  labor;  third,  relief  of  the  focal 
infection  cures  the  posterior  parametritis  in  the  uterosacal  ligaments, 
and  cures  the  lumbosacral  backache  which  is  such  a  prominent  symptom 
in  chronic  endocervicitis. 


CHAPTER  II 

GONORRHEA 

General  considerations  regarding  gonorrhea — Frequency  of  gonorrhea — Gonorrheal 
vulvitis — Condyloma  acuminata — Urethritis  and  bartholinitis — Gonorrheal  vaginitis 
— Cervical  gonorrhea — Gonorrheal  endometritis — Histology — Differential  diagnosis 
— Histology  of  chronic  endometritis — Pathology  and  histology  of  gonorrheal  metri- 
tis— Gonorrheal  inflammation  of  the  fallopian  tubes — Characteristics  peculiar  to 
gonorrheal  infection — Microscopic  appearances  of  gonorrheal  salpingitis — Pyo- 
salpinx — Gonorrheal  inflammation  of  the  tubes  and  ovaries — Acute  pelvic  in- 
flammation— Chronic  pelvic  inflammation — Treatment  of  gonorrheal  infections — 
Acute  specific  urethritis — Acute  specific  vaginitis. 

General  Considerations. — The  essential  cause  of  gonorrhea  is 

the  gonococcus  of  Neisser  (discovered  in  1897).    The  gonococcus  is  an 
intracellular  diplococcus  of  a  double  "biscuit  shape."    The  two  halves  are 
separated  by  a  narrow  open  space.     It  appears  in  groups  of  four,  or 
multiples  of  four.     It  is  small,  non-motile,  and  does  not  have  spores. 
The  gonococcus  is  stained  with  methylene  bkie,  but  does  not  take  the 
gram  stain.     It  is  common  to  find  groups  of  these  cocci  within  pus  cells 
and  at  the  margin  of  epithelial  cells.    They  are  never  arranged  in  chains. 
The  gonococcus  may  be  positively  identified  by  the  microscope.    By  ob- 
serving the   following  rules:     i,   the  prepared   microscopical   specimen 
shows  the  presence  of  a  kidney  or  biscuit  shaped  diplococcus  in  groups 
of  two  or  four,  or  multiples  of  four;  2,  the  situation  of  the  coccus  is 
within  the  body  of  the  pus  cell,  though  other  bacteria  may  also  be  located 
intracellularly ;  3,  gonococci  do  not  take  the  gram  stain;  4,  the  gonococcus 
will  not  grow  on  gelatin  or  agar.     Not  only  is  the  bacteriological  diag- 
nosis of  gonorrhea  of  the  highest  medical  and  medicolegal  importance, 
but  bacteriologic  examination  is  of  considerable  prognostic  value,  as  the 
number  of  gonococci  is  usually  in  direct  ratio  to  the  acuteness  and  viru- 
lence of  the  infection.     Furthermore,  no  case  of  gonorrhea  should  ever 
be  discharged  as  cured  until  repeated  examinations,  particularly  on  the 
day  following  the  cessation  of  menstruation,  have  failed  to  demonstrate 
the  presence  of  the  gonococcus. 

While  it  is  easy  to  confirm  the  clinical  diagnosis  of  gonorrhea  with 
the  miscroscope  in  acute  infections,  in  the  chronic  stage  the  finding  and 
recognition  of  the  gonococcus  is  frequently  exceedingly  difficult,  owing 

31 


32 


PELVIC  INFLAMMATION  IN  WOMEN 


to  some  of  the  following  conditions  which  are  constant  complications  in 
chronic  infection:  i,  there  are  commonly  but  a  few  gonococci  present, 
and  these  frequently  lie  deep  in  the  gland  crypts,  only  appearing  during 
exacerbations  of  the  local  inflammation,  yet  they  retain  their  infective 
qualities;  2,  in  chronic  inflammations,  not  only  are  the  gonococci  few 


INFECTION 
SEALING  TUBE; 

PYOSALPINX 


Fig.  19.- 


-Diagrammatic  Drawing,  Showing  the  Course  of  Gonorrheal  Infection 
Through  the  Uterus  to  the  Peritoneum. 


and  far  between,  but  there  are  also  millions  of  other  bacteria  present, 
which  make  the  recognition  of  the  gonococci  lying  between  and  mixed 
up  with  them  a  most  difficult  task;  3,  among  urethral  parasites  there 
are  found  occasionally  diplococci  which  show  a  marked  similarity  to  the 
gonococcus,  so  that  to  decide  whether  the  diplococcus  found  is  a  genuine 
gonococcus,  sometimes  presents  great  difficulties.    Quoting  from  Neisser, 


GONORRHEA  33 

"it  has  been  asserted  by  some  authorities  that  gonococci  change  in  re- 
gard to  their  forms,  and  that  they  can  assume  quite  uncharacteristic  ap- 
pearances of  degeneration  without  losing  thereby  their  capacity  for 
multipHcation  and  their  virulence,  making  it  in  this  way  possible  for 
gonorrhea  producing  bacteria  to  pass  unrecognized  on  account  of  the 
absence  of  all  of  their  morphological  peculiarities."  Neisser  says  he  has 
never  been  able,  so  far,  tO'  satisfy  himself  about  the  existence  of  such 
forms  of  degeneration;  4,  the  scanty  number  of  gonococci  present  in  a 
genital  tract  are  not  always  accessible  for  examination,  as  they  may  be  in 
hidden  recesses,  for  the  urogenital  tract  in  the  female  is  provided  with 
many  lurking  places,  such  as  the  glands  of  the  cervix,  Skene's  tubules, 
Bartholin's  glands,  and  the  vulvar  pockets,  in  which  the  gonococci  for 
many  months  or  even  years  may  maintain  a  subdued  existence,  yet  ca- 
pable of  producing  relapses  when  alcoholic  or  sexual  excesses  establish 
suitable  conditions,  and  may  thus  retain  their  infectivity  when  brought 
in  contact  with  virgin  soil.  In  these  chronic  cases,  where  the  organisms 
cannot  be  isolated,  the  complement  fixation  test  offers  a  means  of  estab- 
lishing the  presence  or  absence  of  the  gonococcus. 

The  complement  fixation  test  is  particularly  valuable  in  the  diagnosis 
of  chronic  gonorrhea,  for  Schwartz  and  McNeel  state  that  a  positive 
reaction  can  rarely  be  obtained  before  the  fourth  week  of  the  disease; 
and  the  reaction  persists  for  seven  or  eight  weeks  after  the  focal  infection 
is  cured,  hence  a  negative  test  in  a  patient  who  has  previously  had  a  pdsi- 
tive  reaction  is  good  evidence  that  the  disease  is  cured. 

Diagnostic  vaccination  by  the  subcutaneous  injection  of  dead  gono- 
cocci in  persons  suffering  from  gonorrheal  infection  is  followed  by  a 
local  and  general  reaction.  This  reaction  consists  of  an  area  of  swelling, 
redness,  and  tenderness  at  the  site  of  the  inoculation,  and  an  exacerbation 
of  the  symptoms  in  the  pelvis  or  joints,  increased  malaise,  and  some- 
times fever.  According  to  Sternberg,  diagnostic  vaccination  is  of  much 
practical  and  contributory  value  in  establishing  the  diagnosis  of  gonor- 
rhea, when  the  organisms  cannot  be  found  in  the  discharges. 

The  gonococcus  is  not  capable  of  infecting  the  vulvar  and  vaginal 
surfaces  during  sexual  maturity,  when  these  surfaces  are  covered  with 
intact  squamous  stratified  epithelium.  This  is  not  so  when  the  re- 
sistance of  this  epithelial  covering  is  lowered,  as  in  infancy,  or  by  trauma, 
or  old  age.  However,  in  the  urethra,  cervix,  and  body  of  the  uterus,  the 
delicate  cylindric  epithelium  does  not  resist  gonorrheal  invasion,  and  in- 
fection is  possible,  even  without  the  loss  of  the  surface  epithelium. 

The  great  majority  of  infections  in  the  female  is  conveyed  from 
chronic  gonorrhea  in  the  male.     The  writer  believes  that  when  a  man 


34  PELVIC  INFLAMMATION  IN  WOMEN 

has  once  had  a  chronic  posterior  urethritis  and  prostatitis,  he  is  never 
cured  of  his  infection,  and  that  under  the  excitation  of  coitus  he  can 
infect  the  cendx  of  his  wife. 

Noggerath  was  the  first  to  appreciate  the  great  chronicity  of  the 
disease.  Gonorrhea  may  exist  in  the  genital  tract  during  the  period  of 
pregnancy  without  chnical  manifestations  and  become  active  during 
the  puerperium ;  this  explains  some  of  the  late  postpartum  infections. 
It  has  been  proved  that  by  passing  gonococci  through  a  second  individual 
they  may  acquire  added  virulence ;  this  explains  how  an  apparently  cured 
subject  of  chronic  or  latent  gonorrhea  may  infect  his  wife,  and  in  turn 
be  reinfected  by  her.  The  virulence  of  the  gonococcus  is  increased  by 
menstruation,  and  during  pregnancy,  fortunately,  the  dried  gonorrheal 
secretion  is  innocuous. 

The  period  of  inoculation  with  gonorrhea  varies  from  twelve  hours 
to  a  week.  The  part  most  likely  to  be  infected  depends  largely  on  the 
point  of  contact.  If  the  introitus  is  small,  the  urethra  and  Bartholin 
ducts  are  most  liable  to  be  the  seat  of  the  initial  lesion;  while  in  the  parous 
woman  the  cervix  is  most  often  the  seat  of  the  primary  infection.  The 
infection  almost  invariably  begins  as  a  surface  inflammation,  and  spreads 
more  or  less  deeply  into  the  underlying  structures.  The  gonococcus  may 
lie  dormant  in  the  cervical  glands  for  a  prolonged  period  and  spring 
into  activity  under  proper  stimulus.  On  the  other  hand,  protracted  encap- 
sulation, such  as  often  occurs  in  the  adnexa,  tends  to  destroy  the  organ- 
isms. The  gonococcus  is  believed  to  prepare  the  soil  for  subsequent  in- 
fection, such  as  tuberculosis,  or  more  ready  invasion  by  the  pyogenic 
organisms. 

Under  ordinary  conditions  the  gonococcus  rarely  produces  serious 
lesions  in  localities  invested  by  adult  squamous  epithelium,  the  inflam- 
matory reaction  being  due  to  the  toxin  ladened  discharge  from  the  lesion 
higher  up.  In  the  cervical  and  corporeal  mucosa,  however,  a  different 
condition  exists;  the  surface  epithelium  becomes  swollen,  and  the  cells 
become  separated  from  one  another  by  the  inflammatory  exudate; 
desquamation  takes  place,  and  many  of  the  cells  are  replaced  by  a  modi- 
fied epithelium,  or  cicatricial  tissue  may  result;  the  gonococci  quickly 
gain  access  to  the  glands  and  similar  changes  occur  in  the  investing  cells; 
and  the  exudate  is  poured  out  into  the  periglandular  tissues,  so  that  the 
gland  openings  l3€come  occluded  and  filled  with  inflammatory  exudate, 
with  the  formation  of  pseudo  abscesses.  As  the  process  advances,  the 
epithelium  and  its  basement  membrane  may  be  entirely  destroyed,  and 
a  true  abscess  surrounded  by  a  pyogenic  membrane  may  form.  Such  is 
the  pathology  of  an  abscess  of  Bartholin's  gland  or  of  occlusion  cysts  in 


GONORRHEA  35 

the  cervix.  Gonococci  in  the  glands  may  persist  long  after  a  surface 
cure  has  been  effected;  and  from  this  location  reinfection  frequently 
occurs.  This  tendency  to  glandular  penetration,  which  is  possessed  by 
the  gonococcus,  accounts  for  the  resistance  of  the  coccus  to-  gonococcids 
applied  to  the  mucous  surfaces.  From  the  surface  and  gland  crypts  the 
gonococcus  escapes  into  the  stroma  and  underlying  muscular  layer, 
and  in  severe  tubal  infections  even  into  the  serosa  and  adjacent  struc- 
tures. This  migration  excites  a  local  tissue  reaction,  so  that  the  sub- 
mucous structures  become  swollen  and  infiltrated  with  inflammatory 
products  and  the  contiguous  blood  vessels  become  intensely  congested. 
These  reactionary  changes  vary  with  the  severity  of  the  infection,  the 
stage  of  the  disease,  and  the  anatomical  character  of  the  tissue  involved. 
The  underlying  swelling  and  edema  are  accountable  for  a  desquamation 
of  the  surface  epithelium  and  distortion  of  the  parts  by  the  long  con- 
tinued inflammation  in  the  depths  of  the  mucosa,  with  the  formation  of 
cicatrices,  which  interfere  with  lymphatic  drainage  and  consequently 
allow  a  continuance  of  the  symptoms  after  all  signs  of  active  inflamma- 
tion have  subsided. 

This  is  particularly  evident  in  intraperitoneal  pelvic  lesions,  where 
adhesions  and  contractions  so  distort  the  pelvic  anatomy  that  operative 
measures  for  relief  must  be  instituted  for  the  patient's  comfort  and 
health,  rather  than  for  the  cure  of  the  infection.  The  most  marked 
pathological  changes  are  usually  found  near  the  surface,  as  the  tissue  in 
this  locality  seldom  undergoes  complete  resolution.  The  chief  charac- 
teristic of  gonorrheal  inflammation  is  its  chronicity. 

Frequency  of  Gonorrhea. — It  seems  that  the  time  has  arrived 
for  the  physician  to  acquaint  the  public  with  the  general  and  widespread 
evil  effects  of  gonorrhea.  Neisser  states  that  with  the  exception  of 
measles,  gonorrhea  is  the  most  widespread  of  all  diseases.  "It  is  the 
most  potent  factor  in  the  production  of  involuntary  race  suicide,  and  by 
sterilization  and  abortion  does  more  to  depopulate  the  country  than 
does  any  other  cause"  (Norris).  Noggerath  said  that  in  New  York 
city,  of  1000  married  men,  800  have  had  gonorrhea;  that  90  per  cent  of 
all  these  have  not  been  cured  and  can  infect  their  wives;  that  in  New 
York  80  per  cent  of  married  women,  at  least,  have  gonorrhea  or  the 
results  of  it.  While,  at  first  glance,  this  seems  an  extravagant  state- 
ment, our  own  observations  tally  very  well  with  Noggerath's  conclusions. 

In  France,  where  statistics  have  been  accurately  compiled,  it  has  been 
found  that  of  about  10,000,000  families,  2,000,000  are  without  issue; 
these  results,  according  to  Neisser,  would  tend  to  show  that  gonorrhea  is 
the  etiological  factor  in  nearly  1,000,000  sterile  marriages,  and  this  does 


36  PELVIC  INFLAMMATION  IN  WOMEN 

not  include  the  vast  number  of  "one  child  sterilities"  due  to  this  condi- 
tion. 

Unfortunately,  owing  to  the  secret  nature  of  the  malady,  it  is  diflfi- 
cult  to  estimate  accurately  the  actual  frequency  of  the  disease  in  civil 
life;  for  gonorrhea,  attacking  the  genital  tract  below  the  internal  os, 
frequently  produces  only  mild  symptoms,  which  are  wont  to  be  over- 
looked by  the  patient,  and  consequently  she  seeks  no  medical  advice  and 
has  no  treatment ;  while  in  chronic  gonorrheal  infection,  the  local  foci 
are  not  infrequently  overlooked  by  the  average  physician.  Hence  it  will 
be  seen  that  many  female  gonorrheics  not  only  receive  no  treatment,  but 
continue  innocently  spreading  the  infection. 

In  a  study  of  789  cases  of  sterility  observed  by  the  writer,  over  400 
proved  sterile  as  the  result  of  chronic  pelvic  inflammation,  in  which  a 
history  of  gonorrheal  infection  was  definitely  obtainable  and  local  lesions 
demonstrated.  Consequently  the  inhibiting  influence  of  gonorrhea  upon 
the  procreating  capacity  of  women  should  have  very  serious  considera- 
tion. 

Gonorrhea  of  the  cervix  does  not  always  prevent  pregnancy,  but  it 
produces  such  pathology  that  abortion  is  more  frequent  and  this  in  turn 
is  more  apt  to  be  followed  by  a  mixed  infection  which  may  extend  to  the 
tubes  and  peritoneum,  and  result  in  subsequent  sterility. 

The  so-called  "one  child  sterility"  is  accounted  for  in  a  large  measure 
by  the  extension  of  a  preexisting  gonorrheal  infection  during  the  puer- 
perium,  for  it  is  a  well  estabhshed  fact  that  in  the  puerperium  the  infec- 
tion which  was  confined  to  the  cervix  and  urethra  is  likely  to  extend  to 
the  uterine  body  and  tubes,  when  it  will  almost  certainly  result  in  steril- 
ity. Besides  the  serious  effect  which  the  gonococcus  has  upon  the  pros- 
pective mother,  it  is  a  definite  risk  to  the  offspring,  for  in  the  passage  of 
the  child  through  the  infected  maternal  parts  it  undergoes  "a  veritable 
baptism  of  virulence"  (Morrow),  the  eyes  become  infected  and  the  pos- 
sibility of  blindness  is  imminent.  It  is  estimated  that  over  20  per  cent 
of  the  blindness  in  the  world  may  be  ascribed  to  gonorrhea. 

It  is  a  matter  of  clinical  observation  that  a  woman  infected  with 
gonorrhea  may  transmit  the  infection  at  one  time  and  not  at  another. 
This  may  be  explained  where  the  infection  is  confined  to  the  urethra, 
for  urination  shortly  before  coitus  may  temporarily  wash  away  the 
infective  bacteria.  It  has  also  been  observed  that  a  latent  infection 
within  the  uterus  may  not  be  transmitted  l^ecause  the  secretions  of  the 
uterus  do  not  contain  gonococci,  although  in  such  cases  the  gonococcus 
can  usually  be  found  during  the  puerperium  or  immediately  after  the 


GONORRHEA  37 

menstrual  period.  It  is  at  such  times  that  the  husband  may  become  in- 
fected. 

The  more  common  locations  of  latent  gonorrheal  infection  in  mar- 
ried women  are  Bartholin's  ducts,  Skene's  glands,  and  the  cervical  crypts; 
and  extension  frequently  occurs  into  the  uterus  and  pelvic  peritoneum. 

In  infants  and  young  maidens,  the  infection  is  usually  confined  to 
the  vulva  and  vagina,  and  consequently  may  be  spread  by  handling 
diapers,  irrigation  tips,  etc.;  or  be  conveyed  through  contact  with  an 
infected  mother  or  nurse. 

Gonorrheal  Vulvitis. — Gonorrheal  infection  of  the  vulva  has  already 
been  referred  to  under  vulvitis,  but  there  are  certain  peculiarities  which 
should  be  emphasized. 

During  the  acute  stage  the  labia  majora  and  mucosa  about  the  clitoris 
and  the  adjacent  structures  are  red,  swollen  and  tender,  and  bathed  in  a 
profuse  mucopurulent  discharge,  which  contains  gonococci  and  is  ex- 
tremely irritating  to  the  adjacent  skin  surfaces.  It  is  peculiar  to  gonor- 
rhea of  the  vulva  that  the  urethra  and  the  hartholmian  glands  are  com- 
monly attacked. 

Many  observers  claim  that  in  finding  a  purulent  secretion  in  the 
urethra,  and  on  being  able  to  express  pus  from  Skene's  tubules  in  the 
urethral  floor,  or  in  finding  the  mouth  of  the  duct  of  Bartholin  reddened, 
the  diagnosis  of  a  chronic  gonorrheal  infection  is  established  to  a 
moral  certainty. 

It  is  also  not  exceptional  to  find  the  inguinal  glands  enlarged  and 
tender.  But,  notwithstanding  the  clinical  value  of  these  signs,  we  have 
always  hesitated  to  make  a  positive  diagnosis  of  acute  or  chronic  gon- 
ococcic  infection  unless  we  have  demonstrated  the  gonococcus  in  the  pus. 
The  purulent  discharge  often  continues  after  the  acute  process  has  sub- 
sided and  the  subacute  process  is  characterized  by  the  same  symptoms 
and  signs,  all  of  which  however  are  much  less  pronounced.  Some  redness 
usually  persists,  but  the  swelling  and  edema  are  less,  as  is  also  the 
superficial  sensitiveness.  The  discharge  is  yellowish  or  brownish  in  color, 
thick  and  less  profuse,  containing  fewer  gonococci  than  in  the  acute  stage. 
This  discharge,  unless  great  care  is  taken  as  to  cleanliness,  forms 
brownish  crusts  on  the  skin  surface,  and  when  these  are  removed  they 
often  leave  bleeding  ulcers  underneath. 

Condyloma  Acuminata  are  venereal  warts  of  gonorrheal  origin 
which  result  from  irritation  by  the  constant  leukorrheal  discharge  pouring 
over  the  genitals.  They  are  papillary  outgrowths  and  usually  appear 
about  the  vulvar  vestibule,  perineum  or  anus,  occasionally  on  the  vagina 


38  PELVIC  INFLAMMATION  IN  WOMEN 

or  cervix.    Multiple  growths  are  the  rule  and  masses  of  various  size  may 
be  present  in  the  same  case. 

Histologically  the  tumors  are  composed  of  a  hypertrophy  of  the  outer 
layers  of  the  skin,  the  papillae  forming  the  chief  constituents  of  the 
growths.  They  are  moderately  well  supplied  with  blood  vessels,  and 
because  of  this  vascularity  and  the  thinness  of  the  outer  layers  of  the 
epithelium  they  appear  as  whitish,  pinkish  or  purplish  wart-like  cauli- 
flower shaped  masses.  The  surrounding  connective  tissue  generally 
shows  a  moderate  degree  of  chronic  inflammatory  reaction. 

These  masses  may  spring  from  a  broad  base,  or  mav  be  distinctly 
.  pedunculated ;  they  originate  as  papillary  outgrowths,  and  may  remain  as 
such,  or  may  coalesce.    The  surface  of  the  tumors  and  the  surrounding 
skin  are  bathed  in  a  thin,  irritating,  offensive  discharge. 

The  gonorrheal  condyloma  acuminata  possesses  a  distinctly  pointed 
apex  and  only  when  situated  in  the  vagina  become  flattened  as  the  result 
of  pressure.  When  this  occurs  it  presents  a  somewhat  macerated  appear- 
ance, the  irritating  discharge  producing  a  dermiatitis  in  the  surrounding 
skin  surfaces. 

Urethritis  and  Bartholinitis  are  generally  associated  with  gonor- 
rheal vulvitis.  Bartholinitis  and  bartholin  abscess  have  already  been 
discussed  in  a  previous  chapter  among  the  complications  of  vulvitis. 

Gonorrheal  Urethritis. — The  infection  commonly  originates  at  or 
just  within  the  external  urinary  meatus.  On  inspection  the  mucosa  of  the 
external  meatus  is  swollen,  reddened  and  everted,  so  that  the  swollen 
mucosa  protrudes  from  the  urethra.  The  inflammation  commonly  in- 
volves the  mucosa  as  far  back  as  the  urethrovesical  junction.  With  the 
finger  in  the  vagina,  the  urethra  itself  may  be  felt  as  a  tender,  more  or 
less  indurated  band  lying  beneath  the  vaginal  mucosa;  by  pressure 
against  it  with  the  finger  we  may  milk  it  of  a  considerable  quantity  of 
creamy  pus  containing  typical  gonococci.  As  the  disease  becomes 
chronic,  the  discharge  diminishes  and  becomes  mucopurulent  in  charac- 
ter; the  gonococci  decrease  and  finally  disappear  altogether,  except  in 
Skene's  tubules,  which  remain  reddened  and  prominent  and  from  which 
pus  containing  gonococci  may  be  expressed  by  upward  and  forward  pres- 
sure along  the  outer  end  of  the  urethra. 

Gonococci  may  remain  indefinitely  in  Skene's  tubules,  exciting  from 
time  to  time  a  meatus  inflammation  and  maintaining  their  infectivity.  If 
the  inflammation  has  been  severe,  a  certain  amount  of  peri-urethral  in- 
flammation may  remain  for  a  long  time. 

Abscesses  may  form  in  Skene's  glands  or  in  any  of  the  mucous  glands 
of  the  urethra.    They  are  usually  found  on  the  floor  of  the  anterior  por- 


GONORRHEA  39 

tion  of  the  urethra,  and  tend  to  bulge  into  the  vagina.  As  the  inflamma- 
tion subsides,  only  the  reddened,  everted  mucosa  at  the  meatus  may  re- 
main; this  may  involve  the  whole  circumference,  or  protrude  as  a  car- 
uncle from  the  urethral  floor. 

Gonorrheal  Vaginitis. — There  is  nothing  characteristic  in  the  naked 
eye  appearance  of  gonorrheal  vaginitis,  which  distinguishes  it  from  acute 
vaginitis  of  other  etiological  origin.  Hence,  the  history  of  exposure  or 
marriage  and  the  characteristic  associated  lesions  become  of  extreme 
clinical  importance  in  making  a  presumptive  diagnosis,  owing  to  the  fact 
that  after  puberty  the  vagina  is  lined  by  a  modified  skin  and  has  com- 
paratively few  glands.  Acute  vaginitis  during  sexual  life  is  infrequent. 
On  the  other  hand,  in  children  the  outer  layer  of  the  stratified  squamous 
epithelium  is  ill  developed,  which  accounts  for  the  frequency  of  acute 
vaginitis  in  infants  and  little  girls. 

During  the  acute  stage  the  vaginal  mucosa  is  reddened,  swollen, 
edematous,  and  bathed  in  a  creamy,  yellowish  purulent  discharge,  which 
may  be  blood  streaked.  The  normal  acid  reaction  of  the  vaginal  secretion 
is  diminished  or  may  be  alkaline.  In  the  acute  stage  the  inflammation  is 
diffuse,  involving  the  entire  vaginal  tube.  In  the  chronic  stage,  especially 
in  the  young  and  in  the  pregnant  woman,  the  vaginal  mucosa  presents  a 
granular  appearance,  due  to  the  tendency  toward  localization  of  the 
various  groups  of  vaginal  papillae;  consequently  ulcers  or  small  excoria- 
tions are  frequently  found  in  and  about  the  vaginal  vault. 

Clinically,  gonorrheal  vaginitis  cannot  be  distinguished  from  other 
forms  of  vaginal  inflammation,  without  the  isolation  and  microscopic 
recognition  of  the  gonococcus. 

Histologically,  in  the  acute  stage  the  various  layers  of  the  vaginal 
mucosa  are  swollen  and  infiltrated  with  inflammatory  products,  while  in 
the  chronic  stage  the  inflammation  shows  a  tendency  to  localize  in  certain 
groups  of  papillae  in  the  subepithelial  tissue,  and  the  infiltration  inter- 
feres with  the  surface  blood  supply;  hence  the  epithelium  may  desqua- 
mate and  produce  numerous  small  ulcers,  which  give  the  sanguineous 
purulent  character  to  the  discharge. 

On  Microscopic  Section,  immediately  beneath  the  stratified  squamous 
epithelium  we  find  a  well  defined  zone  of  inflammatory  reaction,  i.e.,  an 
infiltration  of  small  round  cells  with  polymorphonuclear  leukocytes; 
serum,  injected  capillaries  and  leukocytes  are  often  found  in  this  over- 
lying epithelium. 

Cervical  Gonorrhea. — The  vaginal  portion  of  the  cervix  at  the 
external  os  is  a  common  seat  of  gonorrheal  infection  in  married  women, 
for  if  the  introitus  is  relaxed,  the  cervix  becomes  the  first  point  of  con- 


40  PELVIC  INFLAMMATION  IN  WOMEN 

tact  and  is  frequently  directly  infected  at  coitus.     Gonorrheal  cervicitis 
may  also  result  from  an  extension  of  the  vulvovaginitis  in  children. 

According  to  Menge,  cervix  infection  is  found  in  about  80  per  cent 
of  all  acute  cases,  and  in  95  per  cent  of  chronic  cases.  The  gonococcus 
seems  to  have  a  selective  affinity  for  the  cylindric  epithelium  lining  the 
cervical  canal,  the  squamous  pavement  epithelium  of  the  portio  having 
the  same  resistance  as  that  of  the  vagina.  The  point  of  transition  from 
flat  to  columnar  epithelium,  however,  varies.  This  point  of  transition 
may  be  without  or  within  the  external  cervical  os,  hence  the  occurrence  of 
the  infection  is  influenced  by  the  location  of  the  cylindric  epithelium. 

For,  according  to  Norris,  "women  in  whom  the  squamous  epithelium 
is  thin,  those  in  whom  the  squamous  epithelium  extends  only  to  the  ex- 
ternal OS,  and  those  in  whom  the  so-called  congenital  erosions  are  present, 
should  be  more  susceptible  to  gonorrheal  infection  than  those  women 
in  whom  the  squamous  epithelium  extends  deeply  into  the  cervical  canal, 
for  gonorrheal  infection  tends  to  localize  itself  in  the  true  mucosa  of  the 
cervical  canal  and  produce  an  endocervicitis." 

When  the  cervix  is  infected  in  the  acute  stage,  there  is  a  plentiful 
purulent  secretion  which  fills  the  upper  part  of  the  vagina;  the  cervix 
is  swollen  and  tender  to  the  touch,  and  as  a  result  of  the  hyperemia 
and  swelling  of  the  mucosa  of  the  canal,  the  mucosa  tends  to  evert  and 
project  itself  beyond  the  external  os,  which  is  seen  to  be  surrounded  by  a 
zone  of  congestion.  If  the  inflammation  persists,  it  may  involve  the 
adjacent  epithelium  of  the  portio,  so  that  the  external  os  appears  as  a 
bright  red  spot  surrounded  by  an  infiltrated  granular  area  covered  with 
a  mucous  or  mucopurulent  discharge.  This  erosion  is  in  reality  an  over- 
growth of  the  lymphoid  structures  within  the  cervical  canal.  It  only 
follows  that,  as  the  cylindrical  epithelium  lining  the  canal  is  continuous 
with  the  cervical  glands,  the  infection  must  penetrate  these  and  thus 
enter  the  tissues  of  the  cervix,  producing  a  coexistent  cervicitis. 

In  the  chronic  stage  the  cer\acal  endometrium  is  rarely  uniformly 
involved ;  a  tenacious  mucous  or  mucopurulent  secretion  bathes  the  sur- 
face and  fills  the  cervical  canal ;  the  mucosa  is  thrown  into  irregular  ele- 
vations, which  become  molded  by  the  cervical  canal  into  polypoid  bodies. 
These  polypi  may  be  one  or  many  in  number,  and  present  or  protrude 
into  the  vagina ;  they  are  apt  to  cause  a  mucosanguinopurulent  discharge 
and  prolong  the  menstrual  flow.  They  bleed  readily  and  occasionally 
bleed  on  coitus.  The  mucosa  contains  numerous  glands  of  the  simple 
crypt  and  racemose  type ;  these  glands  become  the  lurking  places  for  the 
gonococcus  and  are  the  cause  of  the  treatment  being  so  difficult. 


GONORRHEA  41 

Histology. — During  the  acute  stage  the  entire  mucosa  becomes 
edematous,  infiltrated  with  inflammatory  products,  and  the  openings  of 
the  glands,  being  compressed  by  the  inflammatory  infiltration,  become 
more  contracted,  so  that  gland  drainage  is  impaired.  As  a  result,  some 
of  the  gland  openings  become  blocked  and  retention  cysts  result. 

Gonorrheal  Endometritis. — Involvement  of  the  corporeal  endo- 
metrium is  invariably  an  extension  upward  of  the  cervical  infection. 
This  upward  invasion  may  occur  at  a  menstrual  period,  or  shortly  after 
emptying  the  uterus  following  abortion  or  term  delivery,  or  the  infection 
may  spread  upward  as  a  result  of  unnecessary  and  injudicious  local  treat- 
ment or  instrumentation  of  the  cervix,  during  cervical  infection. 

While  gonorrheal  cervicitis  tends  to  become  chronic,  and  exhibits 
little  disposition  toward  spontaneous  cure,  gonorrhea  of  the  corpus  is  a 
self  limited  infection,  the  cure  being  effected  by  resolution.  This  power 
of  self  defense  on  the  part  of  the  corporeal  structures  is  due,  first,  to  its 
rich  blood  supply,  second,  to  excellent  drainage  from  the  body  and  the 
uterine  contraction.  Unfortunately  the  gonococcus,  passing  upward 
past  the  barrier  presented  by  the  internal  os,  often  does  not  stop  in  its 
advance  until  the  tubes  have  been  invaded.  While  the  corporeal  endo- 
metrium almost  always  regenerates  and  becomes  bacteria  free  (Curtis), 
not  so  with  the  endosalpinx ;  hence  it  is  possible  to  conceive  how  the  in- 
flammation of  the  corporeal  endometrium  may  become  reinfected  from 
the  leaking  uterine  end  of  a  pyosalpinx.  In  other  words,  chronic  cor- 
poreal endometritis  does  not  exist  as  a  pathological  entity,  except  in  con- 
junction with  tubal  infection. 

Since  the  work  of  Adler,  Hitschman,  Norris,  Keene  and  Curtis,  we 
have  learned  that  the  endometrial  changes  formerly  described  as  gland- 
ular, interstitial,  polypoid  and  fungoid  endometritis,  are  merely  phases 
of  the  m.enstrual  cycle,  often  changed  in  their  intensity  by  the  contiguous 
lesions  in  the  adnexa  and  adjacent  peritoneum,  which  somewhat  modify 
the  blood  supply  of  the  uterus.  For  it  cannot  be  denied  that  the  endo- 
metrial changes  during  the  menstrual  cycle  are  more  marked  in  a  pro- 
lapsed, subinvoluted  or  retroflexed  uterus,  than  in  one  in  normal  position 
with  an  equalized  efferent  and  afferent  circulation  propelled  by  normal 
healthy  uterine  muscle. 

Most  observers  consider  the  presence  of  the  plasma  cell  a  certain 
criterion  of  inflammation,  and  that  nothing  else  is  so  positive,  though 
Buttner  concedes  that  an  abundant  infiltration  of  leukocytes  is  suggestive 
of  inflammatory  reaction. 

It  is  now  generally  conceded  that  the  diagnosis  of  endometritis  de- 
pends on  the  microscopic  findings.     Both  Frank  and  Norris  believe  that 


42  PELVIC  INFLAMMATION  IN  WOMEN 

glandular  hypertrophy  and  hyperplasia  may  be  due  to  inflammation  as 
well  as  to  ovarian  influence.  Norris  states  that  glandular  and  more  par- 
ticularly interstitial  changes,  of  sufficiently  pronounced  characteristics  to 
warrant  a  diagnosis,  do  occur  as  the  result  of  inflammation,  and  that, 
while  it  is  nearly  always  possible  to  demonstrate  the  plasma  cell  in  both 
acute  and  chronic  cases,  and  while  he  considers  it  of  great  diagnostic 
value,  still  he  is  of  the  opinion  it  is  not  positively  essential  for  the 
diagnosis  of  endometritis.  Further,  that  the  entire  question  should 
not  rest  on  this  one  point;  and  as  further  proof  that  the  glandular  and 
interstitial  changes  are  not  entirely  dependent  on  the  menstrual  cycle, 
he  states  that  it  is  no  uncommon  experience  to  find  in  the  same  en- 
dometrium some  areas  presenting  pronounced  glandular  hypertrophy, 
whereas  in  others  atrophic  or  interstitial  changes  may  be  observed. 

Gonorrheal  endometritis  cannot  positively  be  distinguished  from 
other  forms  of  infection  in  this  locality,  except  by  the  demonstration 
of  the  specific  coccus  in  the  tissue  or  in  the  exudate.  Naturally  this  is 
possible  in  acute  cases  with  their  abundiant  purulent  secretion,  but 
very  difficult  in  the  chronic  lesion  with  infiltration  of  the  tissues  in- 
volving part  of  the  wall  of  the  uterus. 

In  the  Acute  Stage  the  musculature  is  slightly  increased  in  thickness; 
it  is  succulent  from  a  serous  infiltration,  and  turgid  from  the  engorge- 
ment of  the  vessels,  while  the  endometrial  surface  often  presents  a 
granular  appearance. 

Histology. — In  gonorrheal  endometritis  the  most  marked  changes 
are  usually  found  in  the  superficial  portions  of  the  endometrium.  The 
mucosa  is  swollen,  edematous  and  hyperemic,  and  the  surface  may  pre- 
sent areas  of  granulation;  while  other  parts  of  the  surface  epithelium 
may  be  proliferated  and  more  or  less  atypical  in  shape,  size  and  qualities. 
The  glands  show  various  changes;  some  are  normal,  whereas  others 
are  enlarged  or  may  be  cystic.  Occasionally  the  glands  may  appear  to  be 
contracted  from  the  pressure  of  the  inflammatory  exudate  in  the  stroma. 
The  glandular  epithelium  is  rarely  proliferated  or  desquamated,  but 
commonly  shows  evidence  of  inflammatory  reaction.  The  stroma  is 
infiltrated  with  serum,  hence  edematous,  and  contains  polymorphonuclear 
leukocytes  and  blood  cells.  The  blood  vessels  are  congested  and  the  myo- 
metrium is  infiltrated  with  inflammatory  products. 

In  the  Chronic  Stage  the  walls  of  the  uterus  are  thickened,  even  to 
double  their  normal  dimensions;  there  is  an  increase  in  the  firmness  of 
the  texture  and  a  loss  of  the  normal  elasticity,  due  to  an  increase  in  the 
connective  tissue.    This  naturally  disturbs  the  normal  uterine  circulation, 


GONORRHEA  43 

favoring  a  circulatory  stasis,  as  the  contractile  power  of  the  muscle 
tissue  is  impaired  and  promotes  a  vicious  cycle. 

Acute  gonorrheal  endometritis  commonly  terminates  in  resolution, 
owing  to  the  perpendicular  arrangement  of  the  uterine  cavity  (when  the 
uterus  is  in  normal  position),  which  favors  drainage,  and  also  to 
the  abundant  blood  supply  of  the  mucous  membrane. 

On  the  other  hand,  active  inflammation  of  the  endometrium  is 
not  infrequently  kept  up  in  cases  of  pyosalpinx  by  the  leakage  of  pus 
through  the  intramural  portion  of  the  tube  into  the  uterine  cavity.  Owing 
to  the  histologic  arrangement  of  the  endometrium  and  the  investing  of 
the  myometrium  with  utricular  glands,  metritis  must  be  regarded  as  a 
frequent  accompaniment  of  endometritis.  Furthermore,  it  is  important 
to  bear  in  mind  the  relative  infrequency  of  endometritis  as  compared  with 
cervicitis,  and  the  common  association  of  endometritis  with  metritis  and 
adnexal  lesions;  for,  unless  these  facts  are  impressed  on  the  mind  of 
the  practitioner,  the  employment  of  intra-uterine  applications  and  in- 
strumentation will  carry  a  cervical  infection  into  the  uterus  with  exten- 
sion to  the  tubes,  with  most  disastrous  results.  When  left  to  themselves, 
not  more  than  ten  per  cent  of  acute  gonorrheal  infections  of  the  cervix 
extend  above  the  internal  os. 

Symptoms  of  Acute  Gonorrheal  Endometritis. — The  infection 
usually  manifests  itself  shortly  after  a  labor,  abortion,  or  just  after  a 
menstrual  period;  or,  the  infection  of  the  endometrium  may  occur  dur- 
ing menstruation,  for  at  these  periods  the  open  cervical  canal  favors 
the  extension  of  the  infection  from  below. 

When  the  endometrium  becomes  involved,  the  inflammation  may  be 
ushered  in  by  a  chill  or  chilliness,  which  is  seldom  severe;  fever  is  al- 
ways present,  though  the  temperature  rarely  rises  above  102.5°,  while 
both  pulse  and  respiration  are  somewhat  accelerated.  Nausea  and 
vomiting  may  occur,  especially  if  the  infection  is  of  the  severe  type,  as 
is  frequently  found  in  young  married  women  of  blonde  complexion,  or 
in  women  of  the  pituitary  type;  and  rectal  and  vesical  tenesmus  may 
be  present. 

The  woman  usually  complains  of  pain  over  the  lower  abdomen, 
which  is  most  marked  in  the  region  of  the  uterus;  while  some  menstrual 
irregularity  is  frequently  observed.  The  leukorrhea,  which  at  the  onset 
may  be  diminished,  becomes  profuse.  The  discharge  from  the  corporeal 
endometrium  is  copious  and  thin,  unlike  the  thick  tenacious  mucus  from 
the  cervix.  In  gonorrhea,  however,  cervical  infection  invariably  exists 
when  the  corporeal  endometrium  is  involved,  so  that  the  discharge 
from  the  body  becomes  mixed  with  that  of  the  cervix,  giving  the  dis- 


44  PELVIC  INFLAMMATION  IN  WOMEN 

charge  a  mucopurulent,  sanguinopurulent,  or  purulent  character.  It 
is  made  up  of  mucus,  serum,  epithelial  debris,  and  pus,  and  contains 
numerous  intracellular  diplococci. 

Should  a  bimanual  examination  be  made  at  this  time,  the  uterus 
would  be  found  slightly  enlarged,  softened  and  tender;  while  the  cervix, 
which  invariably  participates  when  the  body  is  infected,  is  hypertrophied 
and  tender,  and  the  cervical  canal  is  more  patulous  than  normal. 

Evidences  of  gonorrhea  in  the  urethra  or  external  genitals  are 
nearly  always  present,  and  the  gonococci  may  be  recovered  from  these 
locations  when  it  may  be  impossible  to  demonstrate  them  in  the  leu- 
korrheal  discharge,  unless  a  culture  is  made  from  the  interior  of  the 
uterus,  which  is  a  hazardous  procedure  in  acute  endometrial  inflam- 
mation and  should  never  be  done. 

Differential  Diagnosis. — Acute  gonorrheal  endometritis  has  to  be 
distinguished  from  septic  endometritis  of  the  streptococcic  variety.  This 
is  done  by  the  history  and  the  usual  absence  of  severe  constitutional 
disturbance  and  the  tendency  of  gonorrheal  infection  to  become  chronic. 
Again,  gonorrheal  infection  frequently  extends  to  the  tubes,  while  septic 
endometritis  spreads  to  the  parametrium. 

The  chief  points  that  will  suggest  the  spread  of  the  infection  to  the 
adnexa  are  (i)  the  persistence  and  severity  of  the  symptoms,  (2)  pain 
and  tenderness  in  the  ovarian  regions  with  overlying  muscle  rigidity, 
(3)  vaginal  examination  showing  enlarged  and  tender  tubal  masses  be- 
side or  behind  the  uterus,  (4)  induration  in  the  vaginal  fornices.  Fixa- 
tion and  sensitiveness  of  the  cervix  always  indicate  extension  of  the 
disease  outside  of  the  uterus. 

Histology  of  Chronic  Endometritis. — In  the  chronic  stage,  the 
pathology  is  usually  found  in  the  superficial  position  of  the  endometrium. 
The  surface  epithelium  is  flattened,  and  some  areas  may  be  desquamated, 
while  in  others  there  is  active  cell  proliferation.  The  glands  in  these 
deeper  portions  are  often  enlarged  and  may  in  some  instances,  due  to 
occlusion  or  constriction,  become  cystic.  There  is,  of  course,  an  inflam- 
matory exudate  in  the  stroma  which  disarranges  the  position  of  the 
glandular  elements,  crowding  them  together  on  the  one  hand,  or  widely 
separating  them  on  the  other.  The  glandular  epithelium  undergoes  simi- 
lar changes  to  that  of  the  surface,  though  these  changes  are,  as  a  rule, 
less  pronounced ;  consequently  the  gland  crypt  may  be  empty  or  contain 
serum,  leukocytes,  blood  and  epithelial  debris,  while  the  periglandular 
stroma  is  densely  infiltrated  with  inflammatory  products. 

The  blood  vessels,  which  normally  consist  only  of  endothelial  tulies, 
often  possess  well  developed  muscular  walls  and  are  increased  in  number. 


GONORRHEA  45 

These  superficial  changes,  which  extend  into  the  basal  membrane,  neces- 
sarily involve  the  underlying  uterine  muscle  in  the  inflammatory  process 
and  produce  varying  degrees  of  metritis. 

Pathology  and  Histology  of  Gonorrheal  Metritis. — Gonor- 
rheal inflammation  of  the  uterus  may  be  limited  to  the  cervical  and 
corporeal  mucosa,  but  usually  involves  the  underlying  myometrium  to  a 
greater  or  less  extent,  owing  to  the  peculiar  placement  of  the  utricular 
glands  and  the  uterine  lymphatics.  In  severe  cases  the  inner  layer  of  the 
uterine  parenchyma  is  always  invaded  and  infiltrated  with  inflammatory 
products.  This  causes  the  uterus  to  become  enlarged,  softened  and 
boggy;  the  enlargement  is  general,  but  especially  in  the  transverse  di- 
ameters. Pronounced  cases  of  gonorrheal  metritis  are  commonly  asso- 
ciated with  adnexal  and  peritoneal  inflammations,  which  help  to  keep 
up  the  circulatory  stasis  with  the  subsequent  tissue  changes. 

Symptoms  of  Chronic  Gonorrheal  Endometritis. — Chronic  gon- 
orrheal endometritis  may  occur  as  a  sequela  of  an  acute  infection,  or 
originate  as  a  subacute  process.  When  it  does  occur,  it  is  always  asso- 
ciated with  gonorrhea  of  the  cervix;  hence  it  will  be  seen  why  acute 
exacerbations  frequently  follow  intra-uterine  applications  or  instru- 
mentation, particularly  when  these  manipulations  occur  near  a  men- 
strual period  or  after  a  miscarriage. 

The  most  constant  symptom  of  chronic  gonorrheal  endometritis  and 
endocervicitis  is  leukorrhca.  The  discharge  is  usually  whitish  or  yellow- 
ish in  color  and  thinner  than  that  originating  in  the  cervix.  Microscop- 
ically the  secretion  is  composed  of  serum,  epithelial  debris,  leukocytes  and 
a  few  red  corpuscles. 

Most  authorities  (Hitschman,  Adler,  Keene,  Norris  and  others) 
claim  that  no  mucus  is  secreted  from  the  glands  of  the  endometrium 
except  near  the  menstrual  period,  hence  any  mucus  found  in  the  leu- 
korrheal  discharge  must  necessarily  be  of  cervical  origin. 

In  chronic  endometritis  it  is  extremely  difficult  to  recover  the  gon- 
ococcus  from  the  discharge,  for  not  only  are  the  germs  few  in  number, 
but  they  have  a  habit  of  lying  dormant  in  the  deeper  tissues  and  appear 
only  during  exacerbations. 

Menstrual  disturbances,  as  amenorrhea,  menorrhagia,  and  metror- 
rhagia, are  not  infrequent,  though  profuse  menstruation  is  the  most 
frequent  anomaly.  Congestive  dysmenorrhea  is  a  common  symptom ; 
the  pain  usually  persists  during  the  first  few  days  of  the  flow.  As  stated 
by  Norris,  dysmenorrhea,  occurring  in  women  in  whom  menstruation  has 
previously  been  painless,  and  in  the  absence  of  other  gross  lesions,  espe- 
cially if  gonorrhea  of  other  parts  of  the  genital  tract  exists,  becomes 


46  PELVIC  INFLAMMATION  IN  WOMEN 

a  most  suggestive  symptom.  It  is  also  generally  admitted  that  gonorrheal 
endometritis  is  a  frequent  cause  of  sterility,  though  in  our  experience, 
gonorrheal  cervicitis  is  really  one  of  the  most  common  causes  and  not 
the  inflammation  of  the  corporeal  endometrium. 

Finally,  there  is  usually  found  some  degree  of  enlargement  of  the 
uterus,  due  to  the  associated  metritis.  Knowing  the  power  of  the 
endometrium  to  sterilize  itself  of  bacteria  when  the  uterus  is  in  normal 
position  and  proper  drainage  is  established,  it  seems  strange  that  so 
much  attention  has  been  given  to  chronic  gonorrheal  endometritis.  On 
the  other  hand,  the  cervix  is  never  able  to  rid  itself  of  an  infection, 
hence  we  have  come  to  believe  that  the  chronicity  of  corporeal  infection 
never  exists  clinically,  unless  it  is  associated  with  inflammation  of 
the  tubes. 

Gonorrheal  Inflammation  of  the  Fallopian  Tubes. — Tubal  in- 
flammation of  gonorrheal  origin  is  an  extension  of  the  infection  from 
the  uterine  endometrium  by  direct  continuity  along  the  mucosa.  The 
disease  begins  as  an  endosalpingitis,  but  the  infection  rapidly  invades 
the  muscular  and  serous  coats  and  excites  a  contiguous  peritonitis. 

While  the  disease  is  always  bilateral,  a  different  degree  of  pathology- 
may  exist  In  each  tube;  as,  for  example,  one  tube  may  be  the  seat  of  a 
suppurative  salpingitis,  while  in  the  other  the  infection  may  have 
terminated  in  a  pyosalpinx.  Generally  speaking,  the  more  frequent, 
prolonged,  and  severe  the  attacks  of  pelvic  peritonitis  have  been,  the 
more  extensive  the  tubal  pathology  is  likely  to  be.  The  most  frequent 
pathologic  lesion  produced  by  a  gonorrheal  infection  of  the  tube  is  a 
pyosalpinx. 

Certain  Characteristics  Are  Peculiar  to  Gonorrheal  Infection. — In 
gonorrhea  the  tubal  mucosa  is  primarily  invaded,  while  streptococci  and 
staphylococci  reach  the  tubes,  either  by  the  blood  or  lymphatic  channels 
of  the  broad  ligaments;  hence,  in  these  forms  of  infection,  parametritis 
is  a  constant  associated  lesion  and  perisalpingitis  the  result.  This  para- 
metrial  involvement  is  absent  in  pure  gonococcic  infection  and,  if  cellu- 
litis is  present,  it  is  usually  secondary  to  salpingitis,  being  due  to  the 
pouring  out  of  exudate  into  and  through  the  tubal  wall. 

In  tubal  tuberculosis,  which  makes  up  about  eight  per  cent  of  all 
tubal  inflammations,  the  lesion  is  frequently  secondary  to  tuberculosis 
in  other  parts  of  the  body.  It  is  easily  recognized  at  the  operating 
table,  as  it  produces  a  distinctive  pathology.  Small  miliary  tubercles 
scattered  over  the  surface  of  the  tube,  the  imperfect  closure  of  the  ab- 
dominal ostium  with  a  few  fimbriae  protruding  from  the  partially  closed 


GONORRHEA  47 

ostium,  and  the  cheesy  contents  are  macroscopic  proof  of  the  nature 
of  the  infection. 

An  absolute  diagnosis  of  tuberculosis  can  almost  always  be  made 
with  the  aid  of  the  microscope.  On  the  other  hand,  tubal  infections 
secondary  to  pelvic  peritonitis,  due  to  postpartum  lesions  or  appendicitis, 
affect  the  outer  coats,  producing  a  perisalpingitis,  while  the  endosalpinx 
is  more  or  less  normal  in  appearance. 

Definite  Microscopic  Appearances  Are  Noted  in  Gonorrheal  Sal- 
pingitis.— During  the  acute  stage  the  tubes  become  elongated  and  swollen, 
kinked  and  bent  upon  themselves.  The  surface  is  markedly  congested, 
owing  to  the  increased  vascularity,  and  adhesions  are  nearly  always 
present.  The  increased  weight  of  the  tube  usually  carries  it  down  into 
the  cul  de  sac;  consequently  the  distal  or  free  portion  of  the  tube  shows 
the  greatest  disturbance,  since  this  portion  is  nearer  the  abdominal  ostium, 
through  which  the  infective  material  must  escape.  Hence  the  greatest 
reaction  is  excited  in  the  adjacent  peritoneum,  where  a  plastic  exudate 
is  poured  out. 

On  section,  the  walls  of  the  tube  are  found  to  be  soft,  congested, 
and  edematous,  while  the  mucous  folds  are  reddened,  swollen,  and 
bathed  in  a  purulent  or  seropurulent  exudate.  As  the  disease  tends 
to  become  chronic,  the  abdominal  ostium  closes,  either  by  becoming 
attached  to  some  adjacent  viscus,  or  to  the  parietal  peritoneum  in 
the  cul  de  sac,  or  by  inversion  of  the  fimbriae  and  adhesion  of  their 
peritoneal  surfaces.  When  closure  occurs  by  adhesion  to  some  con- 
tiguous organ  or  the  pelvic  peritoneum,  the  closure  is  seldom  complete, 
and  intermittent  leakage  of  the  infective  contents  is  apt  to  occur,  which 
explains  the  frequent  exacerbations  of  peritoneal  inflammation  so  com- 
mon in  subacute  and  chronic  gonorrheal  tubal  inflammation. 

If  the  disease  tends  to  become  chronic  without  closure  of  the  ex- 
ternal abdominal  ostium,  the  adhesions  on  the  surface  become  more 
dense  and  less  vascular  and  the  walls  become  moderately  firm,  due 
to  the  increase  in  fibrous  connective  tissue. 

Histology. — At  first  the  inflammatory  reaction  is  confined  to  the 
mucosa,  later  there  is  always  more  or  less  involvement  of  the  muscularis; 
as  the  various  coats  become  infiltrated  with  inflammatory  products  the 
surface  epithelium  presents  evidences  of  inflammation,  but  it  is  rarely 
desquamated  or  proliferated,  the  inflammatory  products  tending  to  ex- 
tend through  the  muscularis  along  the  lymph  or  blood  vessels,  where 
groups  of  small  round  cells  or  polymorphonuclear  leukcocytes  may  be 
found. 

Pyosalpinx. — A  pyosalpinx  is  the  usual  termination  of  a  gonorrheal 


48  PELVIC  INFLAMMATION  IN  WOMEN 

salpingitis.  This  results  from  the  closure  of  the  abdominal  ostium  by 
inversion  and  agglutination  of  the  peritoneal  surfaces  of  the  fimbriae. 
How  this  is  actually  accomplished  has  been  the  subject  of  much  discus- 
sion. Whether  it  is  due  to  an  increase  in  the  total  length  of  the  tube 
wall,  which,  by  expanding  in  an  outward  direction,  becomes  projected 
beyond  the  tubal  fimbriae,  and  thus  allows  the  agglutination ;  or  whether, 
as  suggested  by  Ries,  there  is  a  gliding  outward  of  the  "peritoneal  ring" 
over  the  fimbriae,  which  is  made  possible  by  the  fact  that  the  walls  become 
loose  and  redundant,  subsequent  to  the  collapse  of  the  distended  tube, 
seems  of  little  consequence,  so  long  as  inversion  and  adhesion  of  the 
fimbriae  by  their  peritoneal  surfaces  actually  occurs,  for  when  this 
takes  place  the  retained  contents  are  sealed  and  further  infection  from 
leakage  is  prevented. 

On  the  other  hand,  the  perimetric  or  peritonitic  closure  described  by 
Doran,  which  consists  of  a  matting  together  of  the  fimbriae  by  inflam- 
matory adhesions  without  preliminary  recession,  seldom  completely 
closes  the  ostium  and  infective  leakage  frequently  occurs. 

These  purulent  accumulations  form  a  sausage  shaped  tumor  and  are 
chiefly  found  in  the  outer  two  thirds  of  the  tube;  while  the  isthmic  and 
interstitial  portions  show  some  thickening,  but  little  enlargement.  These 
pyosalpinges  vary  markedly  in  size,  from  large  retort  shaped  swellings, 
with  thin  friable  walls,  filling  the  entire  pelvis  and  extending  up  into  the 
abdominal  cavity,  to  small  pyosalpinges  with  immensely  thickened  coats. 
In  recent  cases  the  gonococcus  can  be  recovered  from  the  pus 
by  either  culture  or  smear,  but  in  old  cases  of  long  standing  the 
pus  is  usually  sterile.  In  recent  cases  the  mucosa  is  commonly  found 
intact,  while  in  chronic  cases  of  long  standing  the  mucosa  is  entirely  dis- 
integrated and  replaced  with  a  pyogenic  membrane  or  by  granulation 
tissue. 

Clinical  Course  of  Gonorrheal  Inflammation  of  the  Tubes  and 
Ovaries. — Gonorrheal  inflammation  of  the  endometrium  frequently 
extends  to  the  tubes  and  from  the  tubes  to  the  ovaries  and  pelvic  peri- 
toneum. This  complete  invasion  has  been  observed  to  take  place  in 
less  than  two  weeks  from  the  time  of  the  initial  infection  of  the  cervix. 
The  rapidity  of  the  advance,  however,  is  dependent  on  the  virulence  of 
the  infection  and  the  resistance  of  the  tissues.  When  the  infection  occurs 
near  the  menstrual  period,  or  at  the  time  of  emptying  a  gravid  uterus, 
extension  to  the  tubes  and  pelvic  peritoneum  is  very  rapid. 

Our  clinical  experience  would  seem  to  indicate  that  when  the  cor- 
poreal endometrium  is  infected,  the  disease  extends  to  the  tubes  and  from 
these  to  the  ovaries.     Nevertheless  it  has  been  impossible  to  establish 


GONORRHEA 


49 


with  any  accuracy  the  frequency  of  the  invasion  of  the  adnexa.  Menge, 
in  combining  the  statistics  of  Bumm,  Sternschneider,  Fabry,  Briischke, 
Brose  and  Welander,  found  that  the  tubes,  ovaries  and  pelvic  peritoneum 
were  involved  in  25  per  cent  of  acute,  and  50  per  cent  of  the  chronic 
cases. 

As  we  have  already  stated,  the  primary  tiil^al  lesion  is  an  endosaU 


Fig.  20. — Photograph  from  Author's  Collfxtion,  Showing  How  a  Double  Pyosal- 
piNx  Rolls  Over  and  Covers  the  Ovary.  Both  Tubes  Are  Adherent  in  the 
CuL  DE  Sac. 

pingitis,  but  the  inflammation  quickly  spreads  to  the  deeper  layers  of 
the. tubes,  involving  the  muscularis  and  serosa. 

Gonococci  have  repeatedly  been  found  in  the  depths  of  the  tubal  wall; 
hence  there  must  he  an  accompanying  celhditis  in  the  broad  ligament  in 
extensive  tubal  lesions.  As  a  result  of  the  salpingitis,  an  inflammatory 
exudate  forms,  which  escapes  through  the  tubal  wall,  the  abdominal 
ostium  and  produces  a  peri-oophoritis  and  pelvic  peritonitis.  Fortunately 
the  tunica  of  the  ovary  offers  a  substantial  resistance  to  infection  from 
without,  and  unless  the  infection  directly  invades  a  ruptured  follicle, 
abscess  of  the  ovary  is  unlikely  from  gonorrheal  origin.  On  the  other 
hand,  local  peritonitis  is  common,  and  the  adjacent  pelvic  structures  be- 


50  PELVIC  INFLAMMATION  IN  WOMEN 

come  matted  together  with  the  adnexa  by  extensive  adhesions.  During 
the  exacerbations  of  tubal  inflammation,  which  may  be  excited  by  coitus, 
intra-uterine  instrumentation  or  medication,  more  exudate  escapes  from 
the  tubal  openings  or  through  the  walls  of  the  distended  tube,  and 
further  peritoneal  reaction  is  excited,  owing  to  the  increased  weight 
of  the  free  portion  of  the  tube,  which  is  always  the  site  of  the  greatest 
inflammatory  reaction;  it  rolls  over  and  covers  the  ovary,  and  both 
become  prolapsed  and  adherent  as  tender  swollen  masses  in  the  ad  de  sac 
of  Douglas,  small  purulent  accumulations  being  not  infrequently  found 
between  the  adnexa  and  the  adjacent  structures,  more  or  less  completely 
walled  off  from  the  general  peritoneal  cavity  by  the  sigmoid  and 
omentum.  It  is  not  unusual  to  find  on  one  side  a  large  inflammatory 
mass  composed  of  a  pyosalpinx  and  an  inflamed  ovary,  while  the  other 
tube,  though  infected,  may  have  incurred  little  or  no  damage,  except 
from  the  associated  perisalpingitis.  When  there  have  been  repeated 
attacks  of  pelvic  peritonitis,  it  is  exceptional  to  find  normal  structures 
on  either  side. 

In  the  study  of  the  individual  case,  it  must  be  remembered  that  pelvic 
inflammatory  disease  may  be  produced  by  other  germs  than  the  gon- 
ococcus  alone  and  in  combination;  that  the  gonococcus  prepares  the  soil 
for  other  forms  of  infection,  must  also  be  admitted.  Hence  the  etiology 
of  each  case  of  pelvic  inflammation  becomes  of  the  utmost  importance, 
for  both  the  prognosis  and  treatment  are  largely  dependent  upon  the 
type  of  infection. 

While  it  is  not  always  possible  for  the  surgeon  to  know  positively 
the  form  of  infection  he  is  dealing  with,  clinical  experience  has  taught 
us  that  an  accurate  history  and  appreciation  of  the  site  of  the  local 
lesions  makes  a  presumptive  diagnosis  possible. 

Generally  speaking,  the  majority  of  pelvic  infections  may  be  grouped 
under  three  headings,  gonococcal,  pyogenic,  and  tuberculous,  and  their 
incidence  has  been  variously  estimated  by  different  observers. 

Norris,  in  his  "Gonorrhea  in  Women,"  combines  the  statistics  of 
Andrews,  Menge,  Kronig,  Miller,  Hyde,  Pankow  and  Wertheim,  and 
shows  that  in  specimens  removed  from  the  3501  cases  studied  the 
gonococcus  was  demonstrated  in  lesions  178  times  or  in  17.4  per  cent 
of  the  total.  Such  a  low  incidence,  however,  does  not  represent  the 
actual  proportion  of  cases  which  were  of  gonorrheal  origin;  for  operation 
in  the  acute  stage  is  practically  never  done,  and  in  chronic  cases,  where 
there  has  been  long  encapsulation  of  the  infecting  organism,  the  gon- 
ococcus is  seldom  found,  for  the  organism  has  been  destroyed  either 
by  its  own  toxins  or  the  migration  of  the  colon  bacillus. 


GONORRHEA  Si 

We  would  feel  from  our  clinical  experience  that  over  75  per  cent  of 
all  pelvic  infections  have  a  gonorrheal  origin.  The  importance  of  accu- 
rate diagnosis,  as  to  the  type  of  infecting  organism,  is  shown  by  a  study 
of  the  behavior  of  the  various  organisms  within  the  tubes.  A  large 
proportion  of  gonorrheal  tubes  ultimately  become  sterile  after  a  period 
of  from  six  weeks  to  three  months;  the  death  of  the  infecting  gonococ- 
cus  can  be  assured  if  both  ends  of  the  tube  are  closed ;  it  lives  longer  if 
leakage  occurs.  On  the  other  hand,  the  pyogenic  bacteria  have  an  un- 
known longevity,  even  when  encapsulated,  and  retain  their  virulence  for 
extremely  long  periods. 

Symptoms  of  Acute  Pelvic  Inflammation. — As  an  acute  gonor- 
rheal salpingitis  cannot  occur  as  a  distinct  pathological  entity  without 
associated  infection  of  the  adjacent  viscera  and  peritoneum,  it  is  im- 
possible to  have  a  symptomatology  that  does  not  include  the  symptoms 
and  signs  of  the  peritoneal  reaction. 

Consequently  the  symptoms  must  vary  with  the  extent  of  the  lesion 
and  the  stage  of  the  disease.  The  extension  of  the  infection  from  the 
uterus  to  the  fallopian  tube  usually  follows  a  menstrual  period  or  the 
emptying  of  a  gravid  uterus;  or,  when  the  primary  infection  is  in  the 
cervical  tissues,  upward  extension  is  usually  spread  by  some  form  of 
intra-uterine  instrumentation,  such  as  a  curetting  or  the  introduction  of  a 
stem  pessary. 

The  subjective  symptoms  are  fever,  pelvic  pain,  leukorrhea,  and  a 
bloody  vaginal  discharge.  The  pain  and  tenderness  are  diffused  over 
the  lower  abdomen,  usually  more  marked  on  one  side  than  on  the  other. 
Pain  may  be  considered  as  a  diagnostic  feature,  for  it  is  always  more 
severe  when  the  inflammation  extends  to  the  tubes  than  when  it  is  con- 
fined to  the  uterus.  It  is  usually  intermenstrual  during  the  acute  stage. 
Owing  to  the  fact  that  the  tubal  lesion  is  only  a  part  of  the  general  pelvic 
inflammation,  the  exact  symptomatology  is  difficult.  Usually  when  the 
infection  involves  the  tubes  there  is  a  chill,  followed  by  nausea,  malaise, 
headache,  and  elevation  of  temperature,  and  an  increase  in  the  pulse  rate. 
In  cases  of  gonorrheal  origin  the  temperature  rarely  rises  above  103. 5°F. 
or  the  pulse  rate  above  120.  Commonly  the  readings  are  below  these  fig- 
ures; the  blood  count  shows  a  leukocytosis  and  owing  to  the  tendency 
of  the  inflamed  tube  to  fall  into  the  cul  de  sac  of  Douglas,  rectal  tenes- 
mus is  frequently  complained  of. 

As  we  have  already  stated  in  the  discussion  of  the  pathology,  the 
disease  may  be  unilateral  or  bilateral,  the  tubes  being  involved  simultane- 
ously, or  one  tube  may  be  attacked  at  a  time.  In  severe  cases  the  wide 
spread  abdominal  tenderness,  pain,  and  tympanites  give  a  clinical  picture 


52  PELVIC  INFLAMMATION  IN  WOMEN 

of  general  peritonitis,  and  not  until  some  of  these  acute  symptoms  have 
subsided  is  it  possible  to  recognize  by  vaginal  or  abdominal  examination 
the  actual  evidences  of  tubal  involvement.  Inspection  will  usually  reveal 
evidences  of  gonorrhea  in  the  lower  genital  tract  at  one  or  more  of  the 
common  locations,  i.e.,  at  the  meatus,  in  Skene's  glands,  or  the  mouths  of 
Bartholin's  ducts.  The  cervix  is  enlarged,  soft  and  tender,  always  more 
or  less  fixed,  and  very  sensitive  to  motion;  on  inspection,  it  is  congested 
and  a  purulent  or  mucopurulent  discharge  may  be  seen  issuing  from  the 
external  os.  The  uterus  is  enlarged,  softened  and  tender,  and  induration 
and  sensitiveness  are  present  in  one  or  both  fornices.  As  the  severity  of 
the  acute  symptoms  subside,  it  may  be  possible  to  recognize  on  bimanual 
palpation  an  inflammatory  mass  of  varying  size  occupying  the  region  of 
the  appendages  during  the  acute  stage.  However,  owing  to  the  coincident 
peritoneal  reaction  with  its  tension,  tenderness,  distention,  and  peritoneal 
exudate,  it  is  often  impossible  to  outline  adnexal  lesions.  It  takes  from 
a  week  to  three  weeks  for  the  acute  symptoms  to  subside  and  make 
detailed  palpation  possible. 

Prognosis. — Tubal  involvement  by  the  gonococcus  always  leaves  a 
definite  pathology,  though  complete  regeneration  of  the  tube  is  possible, 
provided  the  infection  does  not  become  a  mixed  one  and  pyogenic  cocci 
do  not  complicate  the  original  lesion. 

Fortunately,  unless  other  bacteria  participate  in  the  general  inflam- 
mation, the  disease  rarely  if  ever  ends  fatally,  but  usually  subsides  and 
becomes  subacute  or  chronic,  only  to  relight  at  irregular  intervals. 

Chronic  Pelvic  Inflammation. — In  chronic  pelvic  inflammation 
there  is  usually  a  history  of  an  acute  primary  infection  with  gradual  sub- 
sidence of  symptoms,  although  some  cases  seem  to  have  followed  a 
chronic  course  from  the  very  beginning.  Acute  exacerbations  of  the 
disease  occur  at  irregular  intervals,  due  to  periodical  leakage  of  the  tubal 
contents,  and  while  these  exacerbations  may  occur  at  any  time,  they  are 
more  prone  to  occur  at  a  menstrual  period,  after  emptying  the  gravid 
uterus,  during  the  puerperium,  or  after  intra-uterine  instrumentation,  or 
excessive  sexual  relations. 

The  woman  with  chronic  pelvic  inflammation  is  always  more  or  less 
invalided,  owing  to  the  inflammation  in  and  about  the  adjacent  struc- 
tures. Menstrual  disturbances  are  common;  these  manifest  themselves 
in  menorrhagia,  metrorrhagia,  and  dysmenorrhea.  There  are  always 
present  symptoms  of  ccnncal  infection;  in  some  cases  amenorrhea  or 
scanty  menstruation  may  be  noted.  This  is  more  often  found  where  there 
have  been  repeated  severe  attacks  of  pelvic  peritonitis,  for  in  such  cases 
the  peri-oophoritis  produced  thickens  the  ovarian  tunic  and  interferes 


GONORRHEA  S3 

with  normal  ovulation.     It  is  difficult  to  conceive  how  an  ovary  can  re- 
main in  such  company  without  participating  in  the  inflammatory  changes. 

In  a  few  cases  of  hydrosalpinx,  intermittent  discharge  of  its  content 
may  occur  through  the  uterus,  and  this  may  be  followed  by  temporary 
relief  of  the  pelvic  symptoms  and  a  subsidence  of  the  tubal  mass. 

Pain  in  the  lower  abdomen  referable  to  the  site  or  sites  of  the  lesions 
is  commonly  present,  and  not  infrequently,  because  of  the  incarceration 
of  the  tubal  mass,  pressure  pains  are  complained  of  in  the  thighs  and 
external  genitals. 

There  are  always  digestive  disturbances,  due  to  the  intestinal  ad- 
hesions which  limit  the  peristaltic  movement  of  the  intestines.  These 
patients  complain  of  gas,  distention,  and  intestinal  colic.  On  the  other 
hand,  in  time  the  inflammatory  process  may  become  quiescent,  and  the 
patient  regain  her  physical  tone.  However,  after  complete  subsidence 
pain  may  usually  be  excited  by  the  use  of  cathartics  and,  in  turn,  be 
relieved  by  rest,  heat  to  the  abdomen,  and  enemata.  Where  the  tubes  and 
ovaries  are  prolapsed  and  adherent  in  the  cul  de  sac,  defecation  is  always 
painful  and  constipation  becomes  a  marked  feature.  Fecal  stasis  in- 
creases the  pelvic  congestion,  and  this  in  time  adds  to  the  pelvic  pain 
and  backache. 

Treatment  of  Gonorrheal  Infection  of  the  Female  Genitals. 
— While  specific  infection  in  its  acute  stage  differs  but  little  from  other 
pyogenic  inflammations,  the  peculiar  characteristics  of  the  gonococcus, 
seeking,  as  it  does,  the  glandular  recesses,  make  its  management  and 
cure  more  difficult. 

In  considering  the  treatment  during  the  acute  stage  of  gonorrheal 
infection,  tzuo  general  principles  must  be  recognised.  ( i )  When  the 
diagnosis  of  acute  gonorrheal  infection  has  once  been  established,  every 
effort  should  be  made  to  prevent  its  upward  extension  along  the  mucous 
surfaces  of  the  genital  organs. 

(2)  We  must  attempt  to  completely  eradicate  the  infection  by  de- 
struction of  the  gonococcus  in  the  involved  areas.  Besides  this,  it  will 
be  necessary  to  relieve  the  patient  of  the  burning  and  suffering  occasioned 
by  the  profuse,  purulent  discharge  which  is  always  characteristic  of  this 
form  of  infection;  and  furthermore,  we  must  instruct  her  as  to  the 
dangers  and  the  possibility  of  contamination  of  herself  and  of  others  by 
the  discharge. 

In  children  the  infection  is  commonly  more  or  less  completely  con- 
fined to  the  vulvovaginal  orifice,  as  the  intact  hymen  virtually  acts  as  a 
barrier  to  the  upward  progress  of  the  disease;  but  when  it  once  passes 
into  the  vagina,  the  inflammatory  reaction  becomes  intense  and,  as  a  rule. 


54  PELVIC  INFLAMMATION  IN  WOMEN 

the  vulva,  vagina  and  cervix  are  all  involved,  and  occasionally  the  uterus 
and  tubes  become  invaded. 

In  the  non-pregnant  adult,  the  mucosa  of  the  vagina  is  particularly 
resistant  to  the  gonococcus,  and  therefore  acts  as  a  natural  barrier  to  the 
infection.  On  the  other  hand,  the  vagina  of  the  pregnant  woman  is  less 
resistant,  and  consequently  often  becomes  the  seat  of  gonorrheal  infec- 
tion, which,  in  turn,  owing  to  the  open  cervix  and  lochial  discharge,  in- 
vades the  uterus  and  tubes  during  the  puerperium. 

The  physician  attending  a  woman  during  the  acute  stage  of  a  vulvo- 
vaginal infection  should  be  impressed  with  the  importance  of  not  carry- 
ing the  gonococcus  higher  up  by  examinations  and  by  various  attempts 
at  local  treatment  through  an  infected  introitus;  and,  before  determin- 
ing what  form  of  local  treatment  shall  be  instituted,  the  external  geni- 
talia should  be  inspected  for  any  inflammations,  reddened  areas,  ulcers, 
or  papillomata.  The  amount  and  character  of  the  discharge  should  be 
determined,  and  on  separation  of  the  labia,  the  condition  of  the  hymen 
observed.  This  exposure  will  also  permit  inspection  of  the  openings  of 
Bartholin's  ducts. 

Inflammation  of  any  type  involving  either  the  gland  or  its  duct  causes 
a  reddening  about  the  duct  opening.  The  typical  maculae  gonorrheae  of 
Sanger,  which  are  considered  as  more  or  less  pathognomonic,  appear  as 
reddened,  elevated  areas  of  three  to  five  millimeters  in  diameter,  having 
the  appearance  of  a  flea  bite.  Many  times,  however,  the  only  evidence  of 
infection  is  a  slight  reddening  about  the  orifice  of  the  duct.  Cultures 
should  be  made  from  the  expressed  secretion. 

The  urethra  is  next  examined;  when  it  is  infected  there  is  redden- 
ing of  the  urinary  meatus ;  the  external  orifice  should  be  wiped  dry  with 
sterile  cotton,  and  the  urethra  milked  b}-  pressure  with  the  finger  from 
behind  forward;  this  exposes  the  orifices  of  Skene's  tubules,  which  appear 
as  small  reddened  pits,  from  which  a  drop  of  pus  exudes. 

The  cervix  is  the  next  point  of  inspection ;  to  do  this,  great  care  must 
be  used  not  to  carry  the  infection  up  from  the  vulvovaginal  orifice  by  our 
manipulations.  The  labia  are  separated  and  wiped  dry  with  sterile  cot- 
ton, and  then  sponged  with  a  i-iooo  bichlorid  solution.  When  all  dis- 
charge about  the  introitus  has  been  removed,  the  cervix  is  exposed 
through  a  suitable  speculum — a  small  trivalve  or  a  Ferguson  tubular 
speculum. 

All  intensely  reddened  area  surrounding  the  external  os,  with  pus 
or  mucopus  exuding  from  the  os,  is  always  characteristic  of  specific  in- 
fection, though  the  positive  diagnosis  in  the  acute  stage  must  never  be 
made  without  bacteriological  proof.     When  the  extent  of  the  infection 


GONORRHEA  55 

has  been  determined  by  such  a  routine  inspection,  the  inflammation 
should  be  confined  as  nearly  as  possible  to  the  area  or  areas  involved.  This 
may  be  done  by  {i) ^ physical  rest  and  (2)  local  cleanliness.  Cleanliness 
is  the  watchword  in  the  treatment,  for  the  profuseness  of  the  discharge 
is  not  only  very  annoying  to  the  patient,  because  of  its  irritating  effect 
on  the  mucous  membranes  and  the  adjacent  surfaces,  but  offers  consider- 
able danger  from  contamination  of  the  patient  herself  and  those  taking 
care  of  her.  The  bacteria  and  their  toxins  are  very  irritating,  and  result 
in  erythema  or  dermatitis  about  the  vulvovaginal  orifice.  When  the 
patient  suffering  from  acute  gonorrhea  presents  herself  for  treatment, 
and  the  above  investigations  have  been  made,  our  first  instruction  should 
be  rest,  and  this  rest  must  he  in  bed.  The  hair  about  the  external  genitals 
should  be  removed  with  scissors,  for  this  allows  more  thorough  cleansing 
of  the  infected  region  and  thus  aids  materially  in  the  subsequent  care. 
Coupled  with  this  the  woman  should  be  advised — 

(i)  To  drink  copiously  of  water  to  increase  her  kidney  function, 
and  so,  by  increasing  the  urinary  output,  wash  away  the  purulent  secre- 
tions from  the  urethra. 

(2)  The  diet  should  be  restricted;  all  meat,  spices  and  condiments 
excluded. 

(3)  In  addition  to  this,  postural  drainage  of  the  genital  tract  should 
be  employed;  this  may  be  done  by  using  the  elevated  trunk  posture  of 
Fowler,  and  from  time  to  time  having  the  patient  change  her  position  by 
allowing  her  to  lie  on  the  abdomen,  in  order  that  the  discharge  in  the 
upper  part  of  the  vagina  may  escape  from  the  vulva. 

(4)  Repeated  vulvar  irrigations  should  be  made  with  the  patient  on 
a  douche  pan,  the  labia  separated,  and  the  irrigant  poured  from  a  pitcher 
over  the  vulvovaginal  orifice.  It  matters  not  what  irrigant  is  used,  as  the 
vulvovaginal  cleansing  is  wholly  mechanical.  However,  our  best  results 
have  been  obtained  by  using  bland  alkaline  irrigants,  such  as  a  combina- 
tion of  bicarbonate  of  soda  and  borax,  in  proportions  of  a  tablespoonful 
of  each  to  two  quarts  of  hot  water,  after  the  pus  has  been  washed  away 
by  the  solvent. 

(5)  Antigonococcic  solutions  may  be  used.  Of  these,  bichlorid  of 
mercury  i  :8ooo,  phenol  i  40,  or  permanganate  of  potassium  or  protargol 
solution  all  have  a  place.  In  our  experience,  permanganate  of  potassium 
has  stood  the  test  better  than  most  of  the  other  antiseptics,  after  the 
vulvovaginal  orifice  has  been  thoroughly  cleansed  and  dried  with  sterile 
cotton. 

(6)  The  vulva  is  wiped  with  cotton  pledgets  soaked  in  a  25  per  cent 
argyrol  or  2  per  cent  silver  nitrate  solution.     Routine  vaginal  douches 


56  PELVIC  INFLAMMATION  IN  WOMEN 

are  not  employed,  for,  no  matter  how  carefully  the  vaginal  douche  is 
given,  it  is  bound  to  disturb  local  conditions,  break  down  the  immunity, 
and  spread  the  infection  upward.  Even  when  the  vagina  itself  is  in- 
volved, the  vaginal  douche  is  seldom  indicated  in  the  acute  stage  of  gonor- 
rhea, for  postural  drainage  and  local  cleanliness  secure  the  removal 
of  the  purulent  discharge;  and  when  it  is  necessary,  because  of  the  sever- 
ity of  the  inflammation,  to  treat  the  vaginal  mucosa,  we  have  found  it 
better  to  make  direct  applications  of  silver  solution  to  the  vaginal  walls, 
for  in  our  practice  we  make  every  effort  to  avoid  the  use  of  vaginal  irri- 
gations until  all  of  the  acute  symptoms  have  subsided,  when  we  make 
direct  applications  of  silver  preparations  to  the  infected  areas  at  the 
meatus,  in  the  urethra,  in  the  vagina  and  cervix.  This  may  be  done 
after  carefully  cleansing  the  introitus  by  introducing  a  skeleton  trivalve 
and  loosely  packing  the  vagina  with  gauze  soaked  in  a  lo  per  cent  solu- 
tion of  protargol;  a  piece  of  cotton  wet  with  the  same  solution  may  be 
placed  between  the  labia.  Should  the  vulvar  pain  be  considerable,  sterile 
gauze  wet  with  aluminum  acetate  solution,  over  which  an  ice  bag  is 
applied,  will  give  the  patient  immediate  comfort. 

From  long  experience  in  the  study  and  management  of  infection, 
to  us  it  seems  better  to  allow  nature  to  establish  its  immunity,  which  is 
the  basic  principle  in  every  infective  inflammation.  It  is  true  that  this 
plan  of  treatment  is  less  radical,  and  oftentimes  takes  longer,  but  the 
complications  are  fewer  than  when  more  active  measures  are  employed. 
We  can  limit  extension  by  favoring  drainage  with  proper  posture  and 
physical  rest,  until  the  acute  symptoms  liave  subsided,  when  an  attempt 
should  be  made  to  eradicate  the  gonococcms  from  the  area  that  has  been 
involved. 

This  may  be  done  by  gonococcids  which  are  easily  applied  to  the 
surface  of  the  vagina  and  the  vaginal  surfaces  of  the  cervix ;  but  when  the 
^onococcus  has  invaded  the  tubular  glands  of  the  urethra,  Bartholin's 
ducts,  or  the  glands  of  the  cervix,  its  eradication  by  any  method  except 
the  total  destruction  of  the  tissue  involved,  offers  little  chance  of 
permanent  cure. 

After  each  defecation  or  urination,  the  external  genitalia  should  be 
carefully  cleansed  with  a  weak  antiseptic  solution.  Rectal  examinations, 
the  administration  of  enemata,  or  the  introduction  of  suppositories  must 
be  absolutely  prohibited  during  the  acute  stage,  with  its  profuse  purulent 
discharge,  for  infection  of  the  rectum  is  most  intractable. 

The  favorite  time  for  extension  of  a  cervix  gonorrhea  to  the  endo- 
metrium and  tubes  is  during  the  last  two  days  of  menstruation,  and  dur- 
ing the  first  few  days  following.     Consequently  it  is  advisable  that  the 


GONORRHEA  57 

patient  should  be  at  rest  at  these  periods,  and  that  all  active  treatment  be 
temporarily  suspended. 

Individual  immunity  is  something  that  is  variable,  for  some  women 
seem  to  be  so  resistant  to  acute  specific  infection  that  they  fail  to  have 
any  noticable  manifestations  of  the  acute  stage. 

Treatment  of  Acute  Specific  Urethritis. — Acute  urethral  in- 
flammation causes  the  patient  to  suffer  from  many  distressing  symp- 
toms, such  as  painful  and  frequent  urination.    The  most  severe  pain  usu- 
ally occurs  during  the  act  of  micturition,  and  then  subsides  slowly.     To 
control  this,  the  urine  must  be  rendered  bland  and  non-irritant  by  the 
exclusion  of  acids,  condiments,  and  stimulants,  the  strict  adherence  to  a 
milk  diet,  and  the  administration  of  copious  quantities  of  pure  or  alkaline 
water.    The  relief  thus  given  is  further  enhanced  by  the  administration 
of  benzoate  of  soda  or  benzoate  of  ammonium  in  ten  grain  doses  every 
three  hours  in  a  glass  of  water.     Salol  in  five  grain  doses  every  two  or 
three  hours  in  warm  water  may  be  employed  instead,  and  rapidly  ren- 
ders the  urine  bland  and  non-irritating.     Unfortunately  the  continued 
use  of  all  of  these  drugs  is  apt  to  upset  the  stomach.    Not  until  all  of  the 
acute  symptoms  have  subsided  should  any  direct  application  or  injection 
be  made  to  the  urethra.    For  the  capacity  of  the  urethra  is  about  fifteen 
or  twenty  drops;  hence,  an  irrigation  of  greater  quantity  or  an  instilla- 
tion of  a  larger  amount  will  force  the  solution  into  the  bladder  and  so 
extend  the  infection  past  the  vesical  neck  and  open  the  way  for  an  ascend- 
ing infection  of  the  urinary  tract.     For  this  reason  we  are  opposed  to 
having  instillations  used  or  urethral  irrigations  made,  but  when  the  in- 
flammation has  become  subacute,  prefer  to  make  direct  application  of 
solutions  of  argyrol,  25  per  cent,  or  silver  nitrate,  two  to  four  per  cent, 
through  an  endoscope  to  the  infected  and  inflamed  areas  within  the 
urethra.     These  rapidly  relieve  the  pain  and  diminish  the  hyperemia. 
After  the  inflammation  has  become  subacute  it  will  be  noticed  that  the 
urethral  infection  is  not  general,  but  is  confined  to  congested  patches  at 
various  points  in  the  canal.    These  should  have  direct  applications  of  a 
two  or  four  per  cent  solution  of  nitrate  of  silver  at  intervals  of  two  or 
four  days,  to  eradicate  the  gonococcus,  while  internally  we  administer 
some  preparation  of  sandalwood  oil. 

By  following  out  such  a  program,  the  relief  of  the  pain  on  urina- 
tion is  usually  pronounced.  Occasionally,  however,  the  pain  and  tenes- 
mus may  be  so  severe  and  intractable  that  it  may  be  necessary  to  ad- 
minister an  anodyne.  Codein  in  generous  quantities  serves  this  purpose 
and,  after  the  acute  discharge  has  ceased,  may  be  employed  in  the  form 
of  codein  suppositories. 


58  PELVIC  INFLAMMATION  IN  WOMEN 

One  general  principle  should  never  be  forgotten  in  the  treatment  of 
urethral  inflammation.  That  is,  that  too  active  treatment  increases  the 
inflammation  and  is  distressing  to  the  patient. 

The  fundamental  principle  is  to  render  the  urine  bland,  and  allow 
the  disease  to  become  confined  to  certain  areas  within  the  urethra,  when 
it  may  be  eradicated  by  direct  destruction  of  the  infection  in  the  diseased 
areas. 

The  vesical  neck,  like  the  internal  cervical  os,  is  a  natural  barrier  to 
upward  extension,  and,  unless  the  treatment  is  so  conducted  as  to  cause 
the  infection  to  pass  along  through  the  vesical  neck,  it  will  remain  in 
the  urethra  and  in  Skene's  tubules  and  not  involve  the  bladder. 

In  the  subacute  and  chronic  stage  Skene's  tubules  become  the  prin- 
cipal seat  of  the  latent  infection,  retaining  the  gonococcus  for  weeks 
and  months  after  it  has  disappeared  from  the  urethra.  These,  not  infre- 
quently, cause  repeated  reinfections  of  the  lower  portion  of  the  urethra; 
but  the  disease  in  these  tubules  may  be  completely  eradicated  by  their 
destruction.  This  can  be  done  after  first  anesthetizing  the  ducts  with 
cocain  or  novocain,  by  injection  into  the  tubules  with  the  probe  pointed 
hypodermic  needle  of  one  or  two  drops  of  pure  carbolic  acid,  or  by 
passing  into  the  tubule  a  very  fine  cautery  knife,  cold,  and  when  in  place, 
turning  on  the  electric  current;  this  destroys  the  tubule  by  opening  it 
up  into  the  urethra.  Only  in  this  way  are  the  tubules  completely  de- 
stroyed and  the  latent  infection  in  them  eradicated. 

Treatment  of  Acute  Specific  Vaginitis. — The  management  of 
acute  specific  vaginitis  differs  in  no  wise  from  the  care  of  acute  vaginitis 
of  other  origins,  except  in  calling  for  care  to  prevent  the  contamination 
of  the  patient  and  others  by  dissemination  of  the  infective  discharge. 

The  patient  should  be  kept  absolutely  quiet  in  bed ;  the  diet  must  be 
confined  to  non-irritating  articles  of  food.  The  free  exhibition  of  saline 
laxatives  is  advisable,  and  the  patient  should  be  encouraged  to  drink 
large  quantities  of  alkaline  waters.  Here  again,  rest  and  cleanliness  are 
the  two  fundamental  principles  in  the  management  of  the  acute  stage. 
Repeated  vulvar  irrigations  of  warm  boric  acid  may  be  used,  and  if  the 
purulent  discharge  is  very  profuse,  a,  vaginal  douche  may  be  given. 
The  bag  should  be  at  a  very  low  elevation,  the  nozzle  introduced  just 
within  the  introitus,  and  the  solution  allowed  to  run  in  and  run  out  under 
low  pressure.  The  ordinary  vaginal  douche,  as  given  by  the  untrained 
nurse  or  physician,  does  more  harm  than  good  in  acute  vaginal  inflam- 
mation. Therefore  it  is  our  practice  to  abolish  as  much  as  possible  the 
routine  use  of  vaginal  douches,  and  allow  the  patient  to  develop  her  im- 
munity against  the  infective  bacteria. 


GONORRHEA  59 

When,  however,  the  acute  symptoms  have  subsided,  direct  antigono- 
coccal  applications  to  the  vaginal  walls,  vaginal  vault,  and  portial  cervix 
may  be  made,  followed  by  carefully  drying  the  walls  and  other  surfaces 
with  sterile  cotton  and  their  separation  maintained  by  the  introduction 
of  gauze  tampons  saturated  with  picric  acid  and  glycerin  or  saturated 
with  a  protargol  or  argyrol  solution.  These  tampons  should  remain  in 
place  for  from  twelve  to  twenty-four  hours,  and  then  be  removed ;  when 
the  surface  of  the  vagina  is  again  exposed  through  a  skeleton  trivalve, 
and  swabbed  with  a  25  per  cent  argyrol  solution  or  a  10  per  cent  protargol 
solution.  Time  should  be  taken  for  this  application  to  thoroughly  dry, 
when  a  powder  of  bismuth  or  bismuth  and  starch,  or  of  warm  Fuller's 
earth  may  be  blown  into  the  vagina  over  all  of  the  vaginal  surfaces. 

This  plan  of  treatment  rapidly  controls  the  discharge.  Only  after 
the  acute  and  subacute  stage  has  passed  are  routine  douches  permissible ; 
then  permanganate  of  potassium  of  a  strength  sufficient  to  make  the 
water  a  port  wine  color  may  be  used  as  a  douche  two  or  three  times  daily, 
with  the  patient  in  the  recumbent  position  on  a  douche  pan,  the  bag  at  a 
low  elevation,  and  the  nozzle  introduced  just  within  the  vulvovaginal 
introitus. 

The  external  cervix,  its  portio,  and  the  external  os  are  almost  always 
involved  when  there  is  a  specific  vaginitis.  Here  again,  the  treatment 
should  be  direct.  The  cervix  should  be  exposed  with  a  proper  speculum, 
and  all  of  its  surfaces  swabbed  with  a  solution  of  ten  to  twenty  grains 
to  the  ounce  of  silver  nitrate,  which  must  always  be  allowed  to  dry  after 
it  has  been  applied.  This  is  then  followed  by  filling  the  vaginal  fornices, 
surrounding  the  cervix,  and  covering  the  exposed  portions  of  the  cervix 
with  warm  Fuller's  earth,  which  is  held  in  position  with  a  loose  gauze 
tampon ;  the  gauze  is  removed  in  about  twelve  hours,  when  a  saline  or 
alkaline  douche  is  given  and  the  surfaces  cleansed.  This  plan  of  treat- 
ment will  control  the  infection,  except  that  portion  of  it  which  has 
entered  the  cervical  canal  and  found  its  way  into  the  glands  of  the  cervix. 

When  it  has  reached  this  point,  local  treatment  has  little  avail,  and 
the  infection  always  becomes  chronic,  causing  considerable  cervical 
hyperplasia,  gland  proliferation,  and  parametrial  extension  into  the  cel- 
lular structures  at  the  base  of  the  broad  ligaments  and  into  the  connec- 
tive tissues  in  the  uterosacrals. 

If  our  treatment  has  not  been  too  radical,  the  infection  mill  remain 
on  the  surface  of  the  cerznx,  and  in  the  cervical  canal  below  the  internal 
OS,  and  gradually  localize  itself  in  the  cei-vical  tissues,  where  it  becomes 
chronic,  causing  a  cystic  cervicitis. 

While  many  different  methods  of  treatment  have  been  suggested  for 


6o  PELVIC  INFLAMMATION  IN  WOMEN 

the  management  of  chronic,  cystic  cervicitis,  with  its  intractable  leukor- 
rhea  and  menstrual  anomalies,  but  two  have  our  endorsement.  Either 
the  entire  glandular  area  of  the  cervix  must  be  excised,  as  suggested  by 
Sturmdorf,  by  employing  the  method  which  is  illustrated  under  the 
treatment  of  chronic  cervicitis,  or  else  the  gland  structures  must  be  de- 
stroyed by  the  substitution  of  scar  tissue,  as  can  be  done  by  the  use  of 
radium  within  the  cervical  canal.  The  latter  method,  so  far,  has  not  been 
employed  long  enough  to  know  its  effect  on  subsequent  pregnancies, 
or  how  the  cervical  tissues  will  act  during  dilatation  in  subsequent 
parturitions;  while,  on  the  other  hand,  excision  of  the  cervix  has  been 
used  successfully  in  the  cure  of  sterility  and  offers  no  obstruction  to  cer- 
vical dilatation. 

Acute  gonorrheal  endometritis  is  managed  on  the  same  general  prin- 
ciples that  acute  infections  of  the  uterus  are  treated  on  when  the  inflam- 
mation is  due  to  other  infecting  agents,  namely,  by  rest,  posture,  ice  bags, 
and  anodynes. 

All  acute  inflammations  of  the  uterus  require  (i)  rest  in  bed  in  the 
elevated  trunk  posture  of  Fowler,  to  secure  postural  drainage;  (2)  the 
application  of  an  ice  bag  above  the  tubes  for  the  relief  of  the  uterine 
pain  and  the  control  of  infectious  extension  to  the  parametrium;  (3) 
the  use  of  moderate  amounts  of  anodynes  for  the  relief  of  the  uterine  and 
pelvic  pain,  and  (4)  the  administration  of  saline  to  relieve  the  pelvic 
congestion. 

The  uterus  is  capable,  as  has  been  shown  by  Curtis,  Norris,  Keen,  and 
others,  of  ridding  itself  of  bacteria  by  its  own  bactericidal  powers. 
Clinically,  we  have  shown  that  it  is  common  for  acute  inflammation  with- 
in the  uterus  to  end  spontaneously  under  this  general  plan  of  treatment. 

No  local  applications,  no  irrigation,  no  instrumentation  is  indicated 
in  the  acute  stage  of  any  gonorrheal  extension  to  the  cavity  of  the  uterus. 

Unfortunately,  extension  to  the  endometrium  means  extension  to  the 
tubal  mucosa,  and  here  again  no  local  treatment  will  have  any  effect  on 
the  actual  pathological  changes  which  take  place  within  the  tubes. 

Only  rest  and  time  will  have  any  effect.  The  patient  will  establish 
her  own  immunity  and,  as  best  she  can,  resist  the  extension  of  the  infec- 
tive invasion. 

The  treatment  of  the  results  of  these  infections,  namely,  that  of  pus 
tubes,  pelvic  peritonitis,  and  their  complications,  will  be  thoroughly  dis- 
cussed under  the  heading  of  "Salpingitis,"  and  it  is  not  necessary  in 
this  chapter  to  make  any  reference  to  the  detailed  management,  except 
to  say  that  the  general  plan  of  treatment  is  rest,  posture,  and  enemata 


GONORRHEA  6i 

to  relieve  congestion  of  the  lower  bowel,  and  finally  sufficient  anodyne 
to  make  the  patient  comfortable. 

These  principles,  with  time,  will  result  in  a  localized  infection  in  the 
tubes  or  pelvic  peritoneum. 

When  all  of  the  acute  symptoms  have  subsided,  and  the  tempera- 
ture has  remained  normal  for  at  least  a  week,  the  leukocyte  count  has 
remained  under  ii,ooo,  the  exudate  has  become  insensitive  and  is  not 
painful  on  manipulation,  and  the  temperature  is  not  elevated  as  a  result 
of  an  examination,  then,  and  not  until  then,  are  any  surgical  procedures 
justifiable. 

Long  experience  has  taught  us  that  the  less  active  the  treatment 
the  better  the  result,  and  the  less  pathology  will  be  found  in  the  pelvis 
when  the  time  comes  for  operative  interference. 

Finally,  the  question  is  often  asked.  How  can  we  determine  that  a 
gonorrhea  has  been  cured?  To  determine  this,  our  examinations  must 
be  thorough  and  repeated;  at  least  three  repeated  negative  examinations 
conducted  over  a  considerable  period  should  show  (i)  the  absence  of 
the  gonococcus,  (2)  the  absence  of  pyogenic  bacteria,  (3)  the  absence  of 
pus  cells  in  the  locations  most  commonly  affected,  namely  the  urethra, 
Skene's  glands,  Bartholin's  ducts,  and  the  cervical  glands* 


CHAPTER  III 

PELVIC  INFECTION'S 
Pelvic  infections — Bacteriology — Mode  of  invasion. 

Acute  puerperal  and  non-puerperal  infections  of  the  female  genital 
organs  and  their  sequelae  make  up  the  largest  group  of  the  diseases 
peculiar  to  women,  with  which  the  obstetric  surgeon  and  gynecologist 
has  to  deal. 

Infection  of  the  female  genitalia  takes  place  either  from  without, 
through  known  avenues  of  entry,  or  from  within  by  a  hematogenous 
route,  in  which  case  the  original  focus  may  be  remote  from  the  pelvis. 
The  peculiar  anatomic  arrangement  of  the  generative  organs  in  women, 
constantly  exposed  as  they  are  to  infection  and  trauma,  directly  favors 
inflammatory  changes.  Furthermore,  certain  periods  in  a  woman's  life 
tend  to  subject  her  to  infection  of  different  types  and  in  different  loca- 
tions; thus  we  find  in  infancy,  with  the  vaginal  introitus  protected  by 
an  intact  hymen,  that  infections  of  the  vulva  and  introitus  are  most 
common.  During  puberty  and  adolescence,  hematogenous  infections  of 
the  endometrium,  tubes,  and  ovaries,  occur  as  local  manifestations  of  the 
exanthemata  and  of  tuberculosis,  and  should  receive  consideration. 
While,  during  the  period  of  sexual  maturity,  with  marriage  and  child 
bearing,  the  woman  may  be  subject  to  all  forms  of  gonorrheal  and  septic 
infection. 

Bacteriology. — Pelvic  infections,  as  do  infections  of  other  tissues, 
result  from  the  introduction  and  propagation  of  infective  organisms 
into  a  favorable  soil.  In  general  we  have  two  classes  of  infective  bacteria. 
the  cocci,  and  the  bacilli.  In  the  former  class  are  found  the  gonococci, 
streptococci,  staphylococci,  pneumococci,  etc. ;  and  in  the  latter  may  be 
mentioned  the  bacillus  coli  communis,  and  the  bacillus  aerogenes  capsu- 
latus.  These  are  the  common  germs  which  play  a  part  in  the  causation 
of  acute  pelvic  infection,  and  have  a  practical  significance  from  lx)th 
the  clinical  and  bacteriological  standpoints. 

The  gonococctis  of  Neisser  is  preeminently  a  surface  germ,  invading 
the  genital  tract  by  continuity  of  structure,  and  negativing  the  acid 
secreting  germ  of  Doderlein.    While  it  is  incapable  of  infecting  the  in- 

62 


PELVIC  INFECTIONS  63 

tact  vulvar  and  vaginal  surfaces,  it  thrives  in  the  urethra,  cervix  and 
utricular  glands.  Its  presence  is  usually  due  to  ejaculated  semen,  but 
it  may  gain  entrance  to  the  vagina  by  innocent  contamination.  It  has 
little  tendency  to  permeate  the  lymphatics  and  seldom  produces  systemic 
poisoning.  Whatever  inflammatory  reaction  is  present  is  due  more  to 
excreted  toxins  than  to  the  presence  of  the  germ  itself. 

Association  with  a  mixed  infection  always  adds  to  its  virulence,  but 
it  has  been  found  in  pure  culture  in  the  tubes  and  in  the  peritoneal  cavity. 
The  gonococcus  may  invade  the  peritoneal  cavity  by  continuity  of  struc- 
ture, travelling  along  the  mucous  membranes,  more  rarely  by  the  blood 
stream  or  lymph  channels ;  though  it  has  been  demonstrated  in  the  blood, 
endocardium,  pleura,  and  peritoneum.  The  usual  route  of  the  gonococ- 
cus is  by  the  mucosa.  The  gonococcus  has  the  faculty  of  preparing  the 
tissues  for  the  invasion  of  other  organisms,  and  by  symbiosis  exalts  their 
virulence  as  well  as  its  own,  and  thus  becomes  a  potent  factor  in  in- 
creasing the  virulence  of  mixed  infection.  The  gonococcus  may  remain 
latent  for  years  in  the  crypts  of  the  vulva,  the  ducts  of  Bartholin's  glands, 
the  urethra,  Skene's  tubules,  and  the  cervical  glands.  The  gonococcus 
produces  no  exotoxin,  but  contains  an  endotoxin  which  is  leukotactic, 
yet  the  bacteria  seem  to  do  but  little  harm  to  the  leukocytes. 

The  other  important  cocci  infectors  are  the  streptococcus  pyogenes, 
and  the  staphylococcus  aureus  and  albus,  of  which  the  staphylococcus 
aureus  is  the  most  common  offender.  These  germs  never  originate  "de 
novo"  nor  are  they  idiopathic,  but  their  natural  habitat  is  the  cutaneous 
surfaces,  mucous  membranes,  and  dirt,  such  as  may  be  found  under  the 
finger  nails  of  the  nurse  or  attendant.  They  enter  the  tissues  through  a 
wound  or  abrasion  and  usually  invade  by  the  lymphatics.  They  infect 
more  quickly  and  with  more  virulence  than  the  gonococcus. 

The  streptococcus  was  discovered  by  Mayerhofer  in  1865,  and 
isolated  in  pure  culture  by  Ogsten  in  1883.  It  may  gain  entrance  at  any 
point  where  solution  of  continuity  has  taken  place  in  the  genital  tract, 
and  passes  at  once  into  the  lymph  spaces  and  along  the  capillaries  to  the 
blood  stream,  without  producing  much  local  reaction  (the  virulence  of 
the  invader  determines  the  amount  of  exudative  resistance  it  excites). 
Consequently  the  serous  or  seropurulent  exudate  poured  out  may  be 
much  or  little.  The  streptococcus,  unless  of  minimal  virulence,  does 
not  produce  soluble  toxins,  but  its  body  contains  hemolysin  and  leukoci- 
din,  although  the  actual  toxic  agent  is  unknown.  The  various  forms  of 
streptococci  are  the  longus,  brevis,  erysipelatis,  capsulatus,  and  viridans. 
Hemolysis  is  not  a  constant  characteristic  and  does  not  indicate  excessive 
virulence,  nor  does  the  length  of  the  chains,  though  it  must  be  admitted 


64  PELVIC  INFLAMMATION  IN  WOMEN 

that  long  chains  are  usually  the  most  dangerous.  The  streptococcus  may 
be  found  on  the  vulva  and  in  the  vagina  of  many  apparently  healthy 
women.  It  exists  in  a  state  of  very  low  virulence  as  a  saprophyte,  which, 
under  proper  environment  and  cultural  influence,  may  become  more  dan- 
gerous. 

The  staphylococcus  was  separated  from  the  streptococcus  by  Ogsten 
in  1883  in  the  pus  from  purulent  infections;  and  Brieger  in  1888  dem- 
onstrated the  staphylococcus  aureus  in  five  fatal  cases  of  puerperal  in- 
fection. The  staphylococcus  occurs  in  various  forms,  e.g.,  the  aureus, 
albus,  flavus,  and  citreus.  This  entire  group  is  frequently  classified  as 
pyococci,  and  they  are  less  invasive  than  the  streptococcus.  They  usually 
cause  a  greater  leukocytic  reaction,  and  by  possessing  leukocidin  and 
proteolytic  ferment,  they  rapidly  kill  the  leukocytes,  liquefy  the  tissues, 
and  produce  pus. 

Local  and  general  leukocytosis  is  characteristic  in  infection  produced 
by  this  bacterium.  The  aureus  and  occasionally  the  albus,  as  demon- 
strated in  four  of  the  writer's  cases,  may  be  of  a  hemolytic  strain.  Severe 
and  fatal  bacteriemias  may  be  caused  by  these  organisms.  These  pyo- 
cocci are  found  on  every  vulva  and  in  most  vaginas  before  labor  and 
during  the  puerperium.  In  these  locations  they  live  as  harmless  para- 
sites, unless  their  virulence  is  exalted  by  such  accidental  conditions  as 
trauma,  abrasions,  and  lacerations,  which  offer  a  port  of  entry  for  their 
latent  energies.  This  is  instanced  in  the  suppurations  found  in  peri- 
neorrhaphies and  many  of  the  parametric  abscesses  seen  postpartum. 

The  bacillus  coli  communis  is  the  chief  organism  inhabiting  the 
large  intestine.  It  closely  resembles  the  typhoid  bacillus  and  is  asso- 
ciated with  many  pelvic  inflammatory  conditions,  in  which  there  are 
intestinal  adhesions.  It  always  migrates  from  the  intestine  through 
adhesion  of  the  intestine  to  the  visceral  or  parietal  peritoneum.  This 
germ  has  been  isolated  from  pus  in  tubal  and  ovarian  abscesses.  It  has 
the  power  to  kill  many  of  the  cocci  which  infect  the  pelvic  structures, 
and  then,  after  rendering  the  contained  pus  free  of  streptococci,  staphy- 
lococci, etc.,  it  dies,  leaving  the  contained  pus  sterile  but  impregnated 
with  its  characteristic  odor. 

In  addition  to  the  bacterial  flora  already  described,  mention  may  be 
made  of  the  bacillus  aerogenes  capsulatus  which  was  discovered  by 
Welch  in  1891.  It  is  a  non-motile,  spore  forming,  encapsulated  gram 
positive  bacillus,  which  is  an  obligate  anaerol^e  that  will  not  grow  in  the 
presence  of  oxygen.  It  is  commonly  classed  as  a  saprophytic  organism, 
living  only  on  dead  tissue,  but  it  produces  a  powerful  exotoxin  which  is 
capable  of  producing  further  tissue  necrosis  and  prepares  the  way  for  the 


PELVIC  INFECTIONS  6$ 

invasion  of  other  organisms,  especially  the  streptococcus.  Its  normal 
habitat  is  in  the  feces  of  humans  and  animals,  and  in  the  soil.  It  has 
occasionally  been  found  in  the  dust  of  hospital  wards. 

Mode  of  Invasion.— Negelius  has  found  the  following  types  of  bac- 
teria more  or  less  constant  in  the  flora  of  the  vulva,  aerobic  streptococci 
and  staphylococci,  the  bacillus  coli  communis,  anaerobic  streptococci  and 
staphylococci,  and  the  bacillus  capsulatus.  If  this  last  named  organism 
is  a  constant  inhabitant  of  the  vulva  and  the  feces  are  constantly  pour-  ^ 
ing  out  its  Welch  bacilli,  it  is  easy  to  explain  how  any  woman  may 
become  infected  through  intravaginal  manipulation  by  the  gas  bacillus. 
Fortunately,  however,  man  is  peculiarly  resistant  to  the  invasion  of  the 
Welch  bacillus,  for  this  organism  does  not  easily  develop  and  propagate 
in  the  body,  unless  it  has  some  dead  tissue  to  live  upon.  All  observers 
agree  that  the  cavity  of  the  uterus  is  free  from  bacteria  during  normal 
pregnancy,  but  during  the  puerperium  organisms  undoubtedly  ascend 
into  the  uterus  from  the  vulva  and  the  vagina,  even  in  women  who  have 
never  been  examined.  Hellendahl  demonstrated  that  this  may  take  place 
along  the  blood  coagula  which  are  usually  present  in  the  upper  vagina 
and  cervix. 

Schottmuller  claims  to  have  isolated  the  Welch  bacillus  from  the 
lochia  of  the  normal  puerperal  woman.  These  facts  show  that  the  puer- 
pera,  with  the  bactericidal  powers  of  her  lochial  blood  during  the  first 
forty-eight  hours,  and  her  leukocytic  zone  after  that,  possesses  one  of 
the  most  wonderful  protecting  organisms  against  infection,  of  which 
we  have  any  example  in  the  body. 

Kronig  and  Menge  in  1907  showed  that  the  liquor  amnii  may  become 
infected  with  the  gas  bacillus  prior  to  the  rupture  of  the  membranes. 
The  writer  has  also  seen  and  reported  one  case  of  gas  bacillus  infection 
at  the  eighth  month,  with  infection  of  the  fetus  and  physometra  with 
membranes  intact.  The  vulva,  vagina  and  cervix  are  the  habitat  of  num- 
berless non-pathogenic  bacteria  which  a/re  normal  to  these  locations. 
Doderlein  isolated  a  vaginal  bacillus  with  acid  secreting  properties,  which 
he  thought  preserved  natural  vaginal  acidity  and  inhibited  the  growth 
of  pathogenic  organisms.  Kronig  has  described  other  non-pathogenic 
germs  in  the  vagina,  and  Stroganoff  noticed  that  during  menstruation, 
vaginal  micro-organisms  increased  in  abundance.  On  the  other  hand, 
all  observers  admit  that  the  uterine  cavity  and  tubes  are  bacteria  free 
in  health.  Recently  Curtis,  in  a  comprehensive  bacteriological  study 
of  the  endometrium  m  health  and  disease,  concludes  that  endometritis 
per  se,  with  bacteria  present  in  smears  or  cultures,  is  practically  unknown 
as  a  clinical  entity,  for,  with  the  exception  of  pyometra  and  in  instances 


66  PELVIC  INFLAMMATION  IN  WOMEN 

of  recent  exploration  of  the  uterine  cavity,  the  endometrium  is  almost 
invariably  free  from  bacteria.  It  is  conceded  that,  though  these  non- 
pathogenic bacteria  in  the  vagina  or  around  the  vulva  and  vestibule  are 
innocuous  in  these  localities,  if  they  arc  introduced  beyond  the  os  exter- 
mmi  and  into  a  favorable  culture  medium  by  any  agency,  they  become 
pathogenic. 

The  vagina  in  the  virgin  is  normally  sterile;  in  the  multipara  how- 
ever, with  a  relaxed  or  torn  vaginal  outlet,  the  lower  part  of  the  canal  is 
covered  on  the  surface  with  bacteria;  but  owing  to  the  stratified  pave- 
ment epithelium  and  the  strong  bactericidal  power  of  the  secretions 
present,  pyogenic  organisms  which  are  introduced  into  the  normally  in- 
tact vagina  are  rapidly  killed. 

As  has  been  stated,  the  uterus  is  normally  sterile ;  but  during  labor, 
abortion,  the  puerperium  and  menstruation,  the  reaction  of  the  vaginal 
secretion  is  changed  by  the  addition  of  blood,  mucus,  etc.,  and  becomes 
less  resistant.  The  organisms  which  are  ordinarily  inactive  multiply 
in  this  congenial  soil,  and  when  an  avenue  of  entrance  is  made,  as  by 
trauma,  infection  follows,  and  of  course  this  may  extend  to  the  uterus. 

Septic  infections  which  occur  in  connection  with  labor,  abortion  or 
the  puerperium  present  features  which  are  characteristic.  The  clinical 
course  is  determined,  first,  by  the  character,  life  history  and  habits  of 
the  infecting  bacteria,  and,  second,  by  the  anatomic  conditions  which  exist 
during  these  periods.  Hence,  in  considering  pelvic  infections  in  women, 
we  necessarly  have  to  study  them  in  the  following  classes:  (a)  Puer- 
peral infections,  (b)  non-puerperal  infections,  (c)  gonorrheal  infec- 
tions. 


TO 
GENERAL 
CIRCULATION 
f 


TO 
LUMBAR 
GLAND5 


TO 
RENAL 


SEPTICEMIA 

THROUGH 
LYMPHATIC5 


SEPTICEMIA 

THROUGH 
VEINJ 


Fig    21. — Diagram   Illustrating   Routes  of  Puerperal  Infections  from   Puerperal 
Wounds  Through  the  Lymphatics,  Placental  Site,  and  Venous  Radicles. 


CHAPTER  IV 

PUERPERAL  INFECTIONS 

Puerperal  infections — Avenues  of  entrance  for  bacteria — Birth  traumatisms — Bac- 
teria of  the  genital  region — Primary  focal  infection — The  puerperal  endo- 
metrium— Puerperal  endometritis — Frequency — Vulvar  infection — Coccal  en- 
dometritis— Cellulitis — Parametritis  and  perimetritis— Differential  diagnosis  of 
cellular  inflammations. 

Puerperal  Infections. — Like  any  other  infection  depending  on 
the  inoculation  of  the  puerperal  wound  by  a  bacterium,  may  be  either 
local  or  general.  Hence  the  infection  may  begin  as  ( i )  a  wound  inocula- 
tion, i.e.,  inoculation  with  the  bacteria  of  any  area  where  the  normal 
reparative  and  healing  process  is  taking  place,  with  an  associated  toxi- 
nemia;  this  is  similar  in  its  pathology  to  the  toxic  absorption  from  the 
sapremia  of  the  older  writers;  or  to  the  toxic  symptoms  produced  from 
lochiometra;  (2)  or,  as  a  wound  infection,  which  may  be  divided  into 
(a)  the  local  process  illustrated  in  the  infected  perineum,  cervix  and  en- 
dometrium, in  which  there  is  a  tissue  reaction  which  limits  the  extension 
of  the  infective  processes;  (b)  the  spreading  of  the  infection  beyond 
the  wound  area,  which  is  due  either  to  the  increased  virulence  of  the 
infecting  bacterium,  or  the  diminished  resistance  of  the  tissues.  This 
spreading  infection  occurs  through  (a')  the  blood  vessels,  in  which  case 
it  may  manifest  itself  clinically  as  a  thrombophlebitis,  pyemia,  or  bac- 
teriemia,  or  (b')  through  the  lymphatics,  producing  parametritis,  peri- 
tonitis, metritis  desiccans,  etc. 

Avenues  of  Entrance  for  Bacteria — Birth  Traumatisms. — 
Traumatisms  of  the  birth  canal  which  may  occur  during  the  course  of 
labor  include  rupture  of  the  uterus,  lacerations  of  the  cervix,  vagina, 
vulva  and  perineum.  These  are  all  contused  and  lacerated  wound's,  con- 
sequently the  tissue  resistance  is  lowered  and  bacterial  inoculation  and 
infective  invasion  are  favored. 

Injuries  to  the  cervix  are  generally  recognized  as  among  the  most  im- 
portant factors  in  the  production  of  puerperal  morbidity,  for  these 
wounds  act  as  the  chief  port  of  entry  for  the  passage  of  bacteria  into 
the  parametrium.  Traumatisms  may  therefore  be  considered  as  the 
principal  avenues  of  entrance  for  the  bacteria  of  the  genital  canal  and 
other  bacteria  introduced  from  without. 

67 


68 


PELVIC  INFLAMMATION  IN  WOMEN 


Bacteria  of  the  Genital  Region. — In  the  great  majority  of  cases 
the  uterus  and  its  contents  are  sterile  before  delivery,  except  in  certain 
cases  of  acute  endometritis  and  in  putrefaction  of  the  dead  fetus  and 
where  the  membranes  have  been  long  ruptured.  A  healthy  vagina  may 
harbor  numberless  pathogenic  germs,  which  have  migrated   from  the 

vulva,  and  yet  these 
bacteria  do  not  infect, 
unless  the  surface  epi- 
thelium is  broken  by 
trauma.  During  labor 
and  after  delivery  the 
bacteria  which  are  har- 
bored in  the  vagina  may 
manage  to  reach  the 
uterine  cavity,  where, 
under  favorable  condi- 
tions, they  are  de- 
stroyed by  the  bacteri- 
cidal action  of  the  uter- 
ine secretions.  Ordi- 
narily during  the  course 
of  normal  involution 
with  proper  uterine  re- 
traction and  drainage, 
the  uterus  is  capable  of 
sterilising  its  cavity. 
However,  when  the  re- 
traction and  contrac- 
tion are  poor  the  con- 
tained bacteria  not  only 
multiply  with  amazing 
rapidity,  owing  to  the 
retained  blood  clots 
which  act  as  culture  media,  but  many  gain  entrance  to  the  uterine  and 
para-uterine  tissues,  as  has  been  shown  by  Sampson,  through  the  lymph 
channels  or  venous  radicles.  Hence,  the  bacteriology  of  the  vulva,  vagina 
and  uterine  cavity  in  these  cases  is  practically  the  same,  for  we  simply 
have  an  upward  migration  of  the  vulva  germs.  Saprophytes  and  patho- 
genic cocci  may  occur  side  by  side,  and  the  saprophytes  sometimes  develop 
pathogenic  qualities,  while  the  pathogenic  bacteria  may  play  the  role  of 
saprophytes.     Furthermore,  it  must  not  be  forgotten  that  ordinary  pyo- 


FiG.  22. — A  Relaxed  Uterus  After  a  Curetted  Abor- 
tion. It  Allows  the  Barium  Solution  to  Be 
Forced  into  the  Veins.     (Sampson.) 


PUERPERAL  INFECTIONS 


69 


genie  cocci,  acting  temporarily  as  saprophytes  or  scavengers,  may  become 
virulent,  and  that  ordinary  putrefactive  bacteria  may  in  the  presence  of 
the  proper  culture  media  (as  blood  clots,  pieces  of  placenta,  membranes, 
etc.)  multiply  so  rapidly  on  this  dead  material  that  they  are  capable  of 
producing  a  severe  toxinemia. 

Pathology. — Infections  first  appear  in  the  puerperium  as  (i)  local 
infections,  which  may  be  primitive  or  consecutive,  or  as  (2)  blood  states, 
including  toxinemia,  bacteriemia  and  pyemia.  A  local  infection  may  or 
may  not  be  associated  with  toxinemia  or  bacteriemia,  while  in  the  blood 


Fig. 


23. — When     the    Endometrium     Is     Intact    and    the    Uterus     Contracted 
Barium  Solutions  Cannot  Be  Forced  into  the  Veins.     (Sampson.) 


states  a  toxinemia  may  occur  without  bacteriemia.  Local  infections  may 
be  divided  into  those  which  are  primary  or  primitive,  and  those  which 
are  consecutive. 

Primary  local  infection  is  the  direct  inoculation  of  a  wound  by  germs, 
while  consecutive  lesions  result  from  the  extension  of  the  infection 
though  the  lymphatics  or  blood  stream.  As  illustrative  of  primary  local 
lesions,  we  have  (a)  puerperal  ulcers,  (b)  endometritis.  These  lesions 
develop  from  the  inoculation  of  germs  into  traumatized  or  wounded 
areas,  as  the  inoculation  of  lacerations  of  the  vulva,  vagina,  perineum, 
cervix,  or  the  endometrium,  which  result  in  a  puerperal  ulcer,  having  the 
same  pathology,  whatever  its  location. 

A  puerperal  ulcer  is  a  simple  wound  infection  and  is  usually  met  with 
in  the  form  of  infected  lacerations  of  the  vulva,  vagina  and  cervix.  These 
primary  injuries  are  commonly  lacerated  wounds,  which  naturally  tend 


70  PELVIC  INFLAMMATION  IN  WOMEN 

to  heal  by  the  normal  process  of  wound  repair;  but  if  the  vaginal  secre- 
tion or  lochia  contains  virulent  pyogenic  bacteria,  wound  inoculation  takes 
place,  and  if  the  wounds  have  been  closed  with  sutures,  the  sutures  cut 
through,  and  suppuration  takes  place  along  the  suture  tract.  Infection 
of  the  wound  excites  in  the  immediate  surrounding  tissues  a  tissue  reac- 
tion with  the  formation  of  a  more  or  less  complete  defensive  wall  of  leu- 
kocytes. The  ulcer  is  usually  covered  with  a  diphtheroid  false  membrane. 
due  to  the  irritating  properties  of  the  bacterial  toxins.  If  the  leukocytic 
and  tissue  reaction  is  sufficient  to  prevent  further  bacterial  extension,  the 
tissues  immediately  surrounding  the  ulcer  become  infiltrated  with  exu- 
date and  the  false  membrane  is  exfoliated,  leaving  a  granulating  wound 
surface  which  is  protective.  During  the  tissue  reaction  there  is  always 
some  toxin  absorption,  i.e.,  a  mild  toxinemia.  It  is  also  possible  for  a 
blood  stream  infection  to  have  its  source  in  the  infection  of  a  perineal  or 
vaginal  wound  by  hemolytic  cocci,  for  cocci  of  this  type  excite  little  or 
no  local  protective  tissue  reaction.  These  ulcers  are  frequently  associated 
with  septic  endometritis,  in  which  case  they  represent  only  a  minor  com- 
plication. When,  on  inspection,  the  cervix  is  seen  to  be  free  from  such 
ulcerative  changes,  it  is  usually  conceded  that  there  is  no  intra-uterine 
lesion. 

THE  PUERPERAL   ENDOMETRIUM 

The  endometrium,  after  labor  or  abortion,  should  be  considered  as  a 
traumatized  zvound  undergoing  the  normal  process  of  wound  repair,  and 
may  be  infected  by  pathogenic  microorganisms,  in  which  case  it  is  virtu- 
ally a  large  puerperal  ulcer.  It  must  not  be  supposed  that  the  presence 
of  necrotic  decidua  or  even  a  piece  of  retained  placenta  within  the  cavity 
of  the  uterus  will  produce  an  endometritis.  In  order  to  have  an  inflam- 
matory reaction  there  must  be  infection.  Retained  products  of  concep- 
tion simply  act  as  culture  media  for  bacteria,  and  prevent  proper  retrac- 
tion and  contraction  of  the  uterus,  which  in  turn  diminishes  the  normal 
protection  of  the  individual  against  bacterial  invasion. 

The  writer  has  repeatedly  left  pieces  of  membranes,  and  in  many  in- 
stances the  entire  placenta,  within  the  uterus  for  days,  without  having  an 
endometritis  produced,  at  least  there  has  been  no  constitutional  reaction, 
and  these  ovular  remnants  have  been  cast  ofif  spontaneously  and  normal 
involution  has  then  progressed  naturally. 

Unfortunately  the  practitioner  is  too  often  unfamiliar  with  many  of 
the  local  changes  which  actually  take  place  in  the  endometrium  after  the 
delivery  of  the  fetus.  During  pregnancy  the  glandular  layer  of  the  deci- 
dua vera  and  serotina  undergoes  a  fatty  degeneration.     The  separation 


PUERPERAL  INFECTIONS  71 

of  the  placenta  and  the  membranes  takes  place  in  this  layer;  hence,  when 
the  uterus  is  emptied  at  the  termination  of  labor,  its  mucous  surface  is 
denuded.  This  leaves  the  connective  tissue  spaces  in  the  basal  membrane 
exposed,  and  at  the  placental  site  the  surfaces  are  bared  almost  to  the 
muscle.  With  this  fact  in  mind,  it  is  easy  to  understand  that  at  the  close 
of  labor  the  entire  interior  of  the  uterus  is  one  large  wound.  At  the  pla- 
cental site,  where  the  connective  tissue  spaces  are  even  more  deeply  ex- 
posed, the  sinuses  contain  superficial  thrombi.  These  open  into  and  pro- 
trude out  into  the  uterine  cavity  and  mark  the  only  irregularity  in  the 
intra-uterine  cavity.  With  the  retraction  of  the  uterus  the  decidua  is  in- 
vaded by  white  blood  corpuscles;  these  form,  a  protecting  layer,  similar 
to  that  which  takes  place  in  any  other  wound,  separating  the  necrosing 
parts  of  the  decidua  from  the  healthy  underlying  granulation  tissue. 

If  we  were  to  inspect  the  interior  of  the  uterus  immediately  after 
labor,  we  should  find  the  endometrium  thickened  to  from  two  to  five  milli- 
meters. The  surface  is  roughened  with  attached  shreds  of  degenerating 
decidua,  blood  clots,  and  bits  of  fetal  membrane.  By  the  third  day  after 
delivery,  as  the  result  of  fatty  degeneration,  these  surface  structures  have 
become  so  softened  that  they  can  be  wiped  off  with  the  finger.  Nature, 
hozvever,  accomplishes  this  exfoliation  by  the  development  of  the  granu- 
lation wall  which  separates  the  dead  from  the  living  structures.  The  re- 
maining decidual  cells  return  to  their  original  condition.  The  remnants 
of  the  utricular  glands  covered  with  epithelium,  which  lie  undisturbed 
among  the  muscle  fibers,  are  brought  closer  together  as  the  uterus  re- 
tracts and  diminishes  its  bulk,  and  the  gland  epithelium,  under  the  stim- 
ulus of  the  circulatory  stasis  thus  produced,  proliferates  rapidly  and 
grows  out  on  the  surface  of  the  endometrium,  thus  forming  the  epithelial 
covering  of  the  new  mucosa.  Hence  it  will  be  seen  that  the  greater  part 
of  the  endometrium  is  cast  off,  and  that  its  regeneration  takes  place  from 
the  connective  tissue  of  the  mucous  membrane  and  from  the  gland  epi- 
thelium, which  proliferates  from  the  deepest  portions  of  the  utricular 
glands.  The  changes  therefore,  which  actually  take  place,  differ  in  no 
way  from  the  changes  which  occur  in  the  healing  of  a  granulating  sur- 
face on  any  mucous  membrane  in  any  part  of  the  body. 

Puerperal  Endometritis. — Pathology. — If  infection  of  the  uterine 
wound  takes  place  by  migration  of  infecting  cocci  from  below  or  by  their 
introduction  from  without,  this  normal  process  of  wound  healing  is  dis- 
turbed and  the  mucous  membrane  becomes  swollen,  rough  and  covered 
with  the  thickened  decidua  in  a  state  of  necrosis.  The  surface  grows 
moist  and  is  covered  with  a  mucopurulent  or  mucosanguineous  smeary 
material.    The  cervix  is  almost  always  coincidently  enlarged,  is  swollen 


72 


PELVIC  INFLAMMATION  IN  WOMEN 


and  eroded,  and  if  lacerated,  the  wounds  are  covered  with  a  diphtheroid 
membrane.  Uterine  invokition  is  arrested  because  of  the  reaction  which 
is  excited  in  the  subjacent  tissues  and  the  consequent  circulatory  stasis 


Fig.   24. — When   the   Endometrium    Is   Injured   the   Barium    Solution    May   Be 
Forced  into  the  Veins.     (Sampson.) 

induced.  The  uterus  becomes  edematous  and  relaxed,  and  this  gives 
the  bacteria  ready  access  to  the  blood  stream  through  the  venous  radicles, 
for  the  terminal  sinuses  empty  into  the  arcuate  veins  and  they  in  turn 
into  the  uterine  veins.    Retraction  of  the  uterus  presents  a  barrier  to  bac- 


FiG.  25. — Veins  Injected  with  Barium   Solution.     (Sampson.) 

terial  invasion,  conversely  relaxation  allows  free  access  to  the  blood 
stream. 

Bumm  descriloes  two  distinct  forms  of  endometritis,  first,  that  which 
is  due  to  putrid  or  bacillary  infection,  in  which  the  bacteria  are  limited 
to  the  surface  and  to  the  necrotic  material  lying  thereon  by  the  pro- 


PUERPERAL  INFECTIONS  73 

tecting  hank  of  leukocytes  and  granulation  tissue;  and  second,  a  coccal 
or  septic  form,  where  the  streptococci  or  pyococci  invade  the  lymphatic 
blood  vessels  by  passing  through  the  protective  wall. 

Unfortunately  this  clean  cut  pathologic  description  is  not  borne  out 
clinically,  for  it  is  seldom  that  the  bacteria  are  wholly  confined  to  the 
decidual  surface,  as  there  are  many  areas  in  which  the  protective  zone  is 
not  so  well  defined  as  to  prevent  bacterial  invasion  into  the  underlying 
tissues. 

In  the  putrid  form  the  surface  endometrium  is  covered  with  thick 
fetid  material,  often  containing  gas  bubbles.  The  surface  is  of  a  greyish 
or  yellowish  or  greenish  color,  or  may  even  be  black,  because  of  the  de- 
composed blood.  It  is  impossible  to  wipe  this  surface  smooth,  as  in  the 
normal  uterus,  owing  to  the  varying  depth  of  the  superficial  necrosis.  If 
the  bacteria  are  virulent,  there  may  be  actual  sloughing  of  the  endome- 
trium; so  that,  instead  of  having  a  smooth,  granulating  surface,  we  find 
patches  of  localized  ulceration  and  the  whole  interior  of  the  uterus  may 
become  putrescent.  This  is  the  case  when  the  putrefactive  bacteria  are 
acting  jointly  with  pyococcic  germs.  If  this  superficial  gangrene  goes 
still  deeper  into  the  uterus,  owing  to  the  greater  virulence  of  the  bac- 
teria, portions  of  the  lining  of  the  uterus,  and  even  some  of  the  under- 
lying muscle  itself,  may  slough  off,  producing  the  metritis  desiccans  de- 
scribed by  Garrigues.  //  the  infection  is  due  to  the  streptococcus  pyo- 
genes and  pyococci  alone,  unmixed  with  saprophytes,  there  is  no  fetor, 
and  the  surface  of  the  interior  of  the  uterus  is  usually  smooth  and  not 
deeply  necrotic. 

While  it  is  usual  for  the  placental  site  to  participate  as  a  part  of  this 
whole  infective  process,  occasionally  the  infection  is  limited  to  the  placen- 
tal site,  and  there  is  little  local  reaction  except  at  this  point.  From  this 
origin  it  is  possible  to  have  severe  thrombophlebitic  extension. 

From  what  has  been  said  it  will  be  seen  that,  in  a  large  majority  of 
cases,  the  bank  of  granulation  tissue  and  leukocytes  is  sufficient  to  limit 
the  infection  to  the  interior  of  the  uterus,  unless  nature's  efforts  are  inter- 
fered with  by  the  meddlesome  obstetrician,  who  insists  that,  because 
there  is  necrotic  material  within  the  uterus,  even  though  it  he  the  result 
of  nature's  conservative  starvation  process,  he  must  remove  it  and  by  so 
doing  break  through  the  barrier  which  nature  has  placed  there  to  pro- 
tect the  organ  against  the  infecting  organism. 

The  infecting  organism  may  be  a  saprophyte  or  pyogenic  coccus,  or 
both  may  be  present  and  here  again,  dependent  upon  the  tissue  resistance 
and  the  virulence  of  the  infecting  cocci,  we  may  have  a  simple  localized 
infection,  in  which  the  formation  of  a  phagocytic  barrier  and  the  occlu- 


74  PELVIC  INFLAMMATION  IN  WOMEN 

sion  of  the  placental  sinuses  protect  the  contiguous  structures  and  the 
general  organism  from  the  extension  of  the  disease.  When  there  is  a 
mild  constitutional  reaction,  like  the  simple  surgical  fever  following  oper- 
ation, i.e.,  toxinemia,  or,  on  the  other  hand,  when  the  microorganisms 
break  through  the  protective  zone  and  invade  the  peri-uterine  tissues  by 
the  lymphatic  route,  or  penetrate  into  the  venous  radicles  and  uterine 
veins,  the  constitutional  intoxication  becomes  severe,  at  times  violent. 

Frequency. — Even  before  Lister's  great  discovery,  obstetricians 
recognized  that  puerperal  fever  was  a  wound  infection,  almost  always 
conveyed  from  without  by  hands  or  instruments.  Kirkland  in  1774 
wrote  describing  its  contagiousness,  while  Gordon  of  Aberdeen  in  1795 
demonstrated  that  the  disease  was  always  conveyed  from  one  patient  to 
another  by  physicians  or  nurses.  Semmelweis  in  Vienna  in  1846  found 
that  the  mortality  of  labor  cases  attended  by  students  engaged  in  post- 
mortem work  and  dissecting  was  four  times  greater  than  that  of  those 
cases  attended  by  the  midwives  in  the  clinic.  By  simply  having  the  stu- 
dents thoroughly  wash  their  hands  he  reduced  the  mortality  of  the  clinic 
from  eleven  per  cent  to  one  per  cent. 

In  hospital  practice,  where  every  detail  in  aseptic  care  is  given  the 
pregnant  and  parturient  woman,  the  mortality  and  morbidity  from  puer- 
peral septic  infection  has  been  brought  down  to  an  almost  irreducible 
minimum.  In  5000  consecutive  confinements  attended  by  the  senior 
students  of  the  Long  Island  College  Hospital  in  the  outpatient  service, 
there  have  been  no  deaths  from  infection.  These  women  have  all  had 
prenatal  attention  in  our  chnic,  and  have  been  delivered  in  their  homes 
by  employment  of  a  simple  aseptic  technic.  No  vaginal  examinations 
were  made,  but  the  progress  of  labor  was  watched  throughout  by  ab- 
dominal and  rectal  examination. 

The  total  morbidity  in  this  series  was  less  than  three  per  cent.  In  our 
morbidity  records  we  include  all  cases  where  a  temperature  of  100.8° 
occurs  after  the  first  forty-eight  hours  and  such  elevation  persists  for 
twenty-four  hours.  On  the  inside  maternity  service  the  morbidity  has 
been  9.3  per  cent.  This  includes  naturally  many  emergency  and  opera- 
tive cases,  which  have  had  vaginal  examinations  through  an  undipped 
vulva  before  admission  to  the  hospital ;  yet  our  mortality  in  the  past 
five  years  has  been  less  than  one  half  of  one  per  cent.  Contrast  this 
with  the  Health  Department  records  of  the  mortality  in  private  practice. 

Dublin,  in  a  statistical  review  of  14,694,260  women  of  child  bearing 
age  between  fifteen  and  forty-four,  found  the  total  death  rate  from  dis- 
eases incidental  to  pregnancy,  parturition,  and  the  puerperium,  to  be  68.4 
per  100,000,  and  43  per  cent  of  this  total  was  from  puerperal  infection. 


PUERPERAL  INFECTIONS  75 

Such  statistics  show  how  Httle  all  of  our  antiseptic  and  aseptic  propa- 
ganda has  done  to  improve  the  technic  of  the  general  practitioner. 

The  midwife  is  often  blamed  for  infection  in  private  practice,  but  an 
extended  experience  in  consultation  work  has  convinced  us  that  the  or- 
dinary foreign  trained  midwife  is  not  a  menace,  but  rather  a  boon  to 
the  parturient  woman.  Would  that  we  could,  as  Williams  suggests,  train 
our  practitioners  to  be  contented  to  be  clean  male  midwives,  and  not  pose 
as  operative  obstetric  surgeons,  without  having  had  any  special  training. 

Puerperal  fever  is  primarily  due  to  infection  of  the  obstetric  ivoiind 
hy  microorganisms.  The  entire  parturient  canal  following  delivery  may 
be  regarded  as  a  wounded  surface,  and  is  therefore  a  suitable  gateway 
for  the  entrance  of  infective  bacteria.  The  uterus,  however,  with  its 
bruised  cervix  and  placental  site,  must  be  considered  the  chief  port  of 
entry.  Infection  may  start  in  wounds  of  the  vulva,  vagina,  cervix,  or  in 
the  uterus  itself. 

Vulvar  Infection. — Infected  wounds  in  this  location  present  the 
same  general  appearance  as  septic  wounds  elsewhere.  In  severe  cases 
they  are  of  a  dirty  greenish  yellow  color,  bathed  in  a  foul  purulent  dis- 
charge, and  called  puerperal  ulcers. 

Septic  wounds  of  the  vagina  after  instrumental  delivery  are  relatively 
common.  It  matters  not  whether  the  injury  results  from  natural  or 
instrumental  delivery,  the  wound  is  a  lacerated  one  in  bruised  tissues, 
which  has  diminished  resistance;  hence,  it  is  easy  for  infection  to  ex- 
tend through  these  wounds,  beginning  in  the  pelvic  floor  and  vagina,  and 
producing  in  the  surrounding  cellular  tissues  paravaginal  inflamma- 
tion. 

Rupture  of  the  vagina,  with  extension  of  the  rent  into  the  cellular  tis- 
sue, peritoneum  or  bladder,  is  becoming  more  and  more  rare  as  the  for- 
ceps is  less  frequently  used ;  yet,  a  superficial  vaginitis  with  purulent  dis- 
charge is  a  common  postpartum  sequela. 

The  cervix  in  every  labor  is  subjected  to  severe  traimnci  and  some  de- 
gree of  laceration,  and  these  wounds  may  become  infected  and  the  infec- 
tion may  extend  into  the  cellular  tissues  surrounding  the  uterus,  or  may 
reach  the  peritoneum  or  the  blood  stream  by  way  of  the  lymphatics  and 
blood  vessels.  A  posterior  parametritis  which  is  very  obstinate  is  not 
an  uncommon  sequel  to  cervix  infections,  and  explains  many  of  the  post- 
partum backaches.  The  uterus  however  must  of  necessity,  either  through 
lacerations,  or  through  its  endometrium  or  the  placental  site,  be  the  chief 
port  of  entry. 

To  properly  understand  puerperal  infection  of  uterine  origin,  one 
must  consider,  for  a  moment,  the  physiological  process  which  takes  place 


76  PELVIC  INFLAMMATION  IN  WOMEN 

within  the  uterus  after  the  evacuation  of  its  contents  as  a  consequence  of 
the  rapid  retraction  and  resulting  hemostasis.  This  sudden  shutting  off 
of  the  blood  supply  leaves  the  endometrium  more  or  less  covered  by  a 
layer  of  necrosing  decidua,  which  is  cast  off  piecemeal  by  a  process  of 
surface  starvation,  due  to  the  active  leukocytosis  and  the  increase  of  the 
connective  tissue  cells  which  take  place  immediately  beneath  the  de- 
cidua. This  forms  a  granulating  zone  which  prevents  the  invasion  of  all 
but  the  more  virulent  bacteria.  The  entire  cavity  of  the  uterus,  except  the 
placental  site,  becomes  a  granulating  wound  by  about  the  end  of  the  first 
week,  protected,  as  is  the  case  in  the  ordinary  surgical  wound,  by  its 
granulating  surface.  In  the  placental  site  the  thrombi  in  the  open  ves- 
sels require  a  longer  time  for  this  organization.  This  site  is  rough  and 
raised,  and  is  covered  with  irregular  masses  of  decidua,  shreds  of  pla- 
centa, fragments  of  villi,  etc.  Organization  occurs  in  the  thrombotic 
sinuses,  while  the  bank  of  granulation  thickens  and  causes  the  exfolia- 
tion of  the  superimposed  masses.  This  occurs  from  the  tenth  to  the 
fifteenth  day.  The  effect  of  infective  bacteria  on  these  normal  healing 
processes  varies  with  the  nature  and  virulence  of  the  microorganisms 
and  the  manner  by  and  the  soil  into  which  they  are  introduced. 

Any  of  the  infecting  organisms,  singly  or  in  combination,  such  as  the 
various  strains  of  streptococci,  the  staphylococcus,  pneumococcus  and 
gonococcus,  as  well  as  numberless  non-pathogenic  bacteria,  may  be  found 
in  the  postabortal  or  postpartum  uterus.  Repeated  culture  of  the  interior 
of  the  uterus  at  various  periods  of  the  puerperium  shows  that  its  contents 
after  the  first  twenty-four  hours  postpartum  are  seldom  sterile;  in  fact 
over  50  per  cent  of  the  cases  zuhicJi  were  cultured  in  our  clinic  on  the 
fifth  and  sixth  day  postpartum  showed  the  presence  of  infective  bacteria 
zvithin  the  uterus,  yet  these  patients  did  not  have  sepsis,  for  the  granula- 
tion zone  zvas  intact.  Puerperal  and  postabortal  infection  of  the  uterus 
must,  therefore,  be  regarded  as  a  wound  infection  with  an  absorption  of 
toxins.  Infection  of  the  puerperal  wound  is  no  different  in  its  pathology 
from  an  infection  of  any  wound  on  the  surface  of  the  body,  except  that 
the  area  of  lymphatic  drainage  is  greater. 

Notwithstanding  the  presence  of  infective  bacteria  in  the  uterine  cav- 
ity, the  uterus  is  normally  protected  from  invasion  from  the  interior  both 
during  and  after  labor.  During  the  labor  it  is  protected  by  (i)  the 
membranes,  though  in  recent  years  Selmons  and  the  writer  have  shown 
that  bacteria  can  penetrate  the  amnion,  if  the  labor  is  prolonged  and  the 
lucnibrancs  have  ruptured  early,  owing  to  the  changes  in  the  amniotic 
endothelium,  which  diminish  its  resistance  and  allow  bacterial  invasion 
of  the  placental  site;  also  by  (2)  the  ^utotoxic  properties  of  newly  let 


PUERPERAL  INFECTIONS  'j'j 

blood.  After  labor  the  uterus  is  protected  by  the  establishment  of  the 
lochial  discharges  and  the  normal  reaction  in  the  uterine  tissues.  This 
is  shown  by  its  protective  granulation  zone,  composed  of  polynuclear 
leukocytes,  eosinophiles,  fibroblasts  and  polyblasts.  Infective  organisms 
must  penetrate  this  zone  or  pass  through  abrasions  or  other  injuries  in  the 
uterine  tissues  to  get  outside  of  the  uterus.  This  the  streptococcus  and 
some  strains  of  the  staphylococcus  have  the  power  of  doing.  The  gono- 
coccus,  on  the  other  hand,  lacks  this  power  of  penetrability,  and  advances 
along  the  mucous  membrane  and  submucous  lymphatics  and  reaches  the 
tubes  and  peritoneum  by  continuity. 

The  primary  inflammatory  lesion  in  puerperal  and  postabortal  infec- 
tion, if  the  infecting  cocci  are  not  of  the  hemolytic  type,  is  found  within 
the  uterus.  Endometritis  is  the  primary  lesion  in  most  cases,  as  seen  by 
the  following  enumeration  of  factors  which  favor  uterine  infection  and 
the  development  or  spread  of  infective  organisms. 

1.  The  cervix  and  lower  uterine  segment  are  particularly  exposed 
to  traumatisms  of  labor  and  to  injury  in  the  course  of  operative  delivery. 

2.  The  cervical  and  uterine  mucous  membrane  is  a  very  delicate  struc- 
ture as  compared  with  that  of  the  vagina,  and  is  covered  with  a  layer  of 
dying  decidua,  which  acts  as  a  favorable  culture  medium  to  the  growth  of 
bacteria. 

3.  Blood  clots,  membrane,  and  even  placental  fragments  may  be  re- 
tained within  a  relaxed  uterus,  and  these  also  may  act  as  culture  media 
for  pathogenic  bacteria. 

4.  Infection  may  have  been  present  in  the  endometrium  during  preg- 
nancy or  have  been  brought  there  directly  by  the  introduction  of  a  col- 
peurynter  or  bougie  or  by  decomposed  liquor  amnii. 

5.  Shreds  of  membrane  from  the  uterus,  hanging  down  into  the 
vagina,  may  act  as  a  bridge  on  which  bacteria  from  the  unsterile  vagina 
may  mount  into  the  uterus. 

6.  The  open  vessels  of  the  placental  site  are  particularly  favorable 
to  the  migration  of  germs. 

7.  If  the  uterus  is  flabby  and  relaxed,  drainage  is  impaired  and  stasis 
of  the  lochia  may  occur,  and  this  produces  a  condition  of  lochiometra 
which  is  particularly  favorable  to  bacterial  growth.  While  all  of  the 
above  mentioned  conditions  predispose  to  intra-uterine  infection,  we 
know  from  clinical  experience  that  the  presence  of  decidua  or  a  piece  of 
placenta  retained  within  the  uterus  will  not  cause  endometritis  unless  in- 
fection is  also  present. 

While  making  our  clinical  investigations  on  this  subject,  we  have  left 
pieces  of  placenta  in  the  uterus  for  weeks  without  harm  or  decomposition, 


78 


PELVIC  INFLAMMATION  IN  WOMEN 


so  long  as  infection  was  not  introduced  by  careless  examination  or  intra- 
uterine instrumentation. 

A  well  contracted  uterus  and  the  Fowler  position,  the  elevated  trunk 

posture,  alternating  this 
posture  with  the  patient 
lying  on  her  abdomen 
to  drain  the  vagina, 
will  expel  decomposing 
clots,  placental  frag- 
ments, and  retained  se- 
cretions. Firm  contrac- 
tion and  retraction  also 
offer  a  barrier  to  bac- 
terial invasion  from  the 
uterine  cavity,  by  clos- 
ing the  lymphatics  and 
blood  vessels.  Sampson 
has  shown  that  in 
will  protect  the  venous  radicles 
of   intra-uterine   bacteria.      On 


Fig.  26. — Barium  Injected  into  the  Contracted  Uterus 
Can  Be  Forced  into  the  Tubes.     (Sampson.) 


abortions    an    intact    endometrium 

in  the  uterine  wall  from   the   invasion 


other 


hand, 
be      cau 


when 
ht 


a    relaxed    uterus    becomes    bent    upon    itself, 


the 

it  may  ..^  ^c...g, 
behind  the  pubis  and 
become  extremely  ante- 
flexed,  or  may  be 
caught  below  the  prom- 
ontory and  become 
retroflexed,  and  so  pre- 
vent the  free  outflow 
of  the  lochia,  thus  pro- 
ducing lochiometra  and 
favoring  the  absorption 
of  toxins.  From  the 
clinical  facts  wc  must 
conclude  that  a  well 
contracted  uterus,  in 
normal  anteversion,  is 
capable  of  emptying  it- 
self of  its  content,  if  infection  is  not  introduced  from  the  outside. 

Putrid  or  saprophytic  endometritis  is  an  infection  of  the  dead  and 
necrotic  superficial  structures  retained  within  the  uterus,  which  produces 


Fig.  27. — Relaxed  Uterus  with   Tube  Injected  with 
Barium   Solution.     (Sampson.) 


PUERPERAL  INFECTIONS  79 

irritant  material  composed  of  bacterial  toxalbumoses  and  ptomains,  which 
in  turn  irritate  the  endometrium  and  excite  a  tissue  reaction. 

These  necrotic  structures  have  bacteria  in  them  or  on  them.  Schott- 
miiller  showed  that  the  majority  of  cases  of  endometritis  putrida  were 
due  to  an  obligate  anaerobic  streptococcus.  In  this  form  of  infection 
the  uterine  tissues  are  protected  from  further  invasion  by  the  presence  of 
the  granulation  zone. 

The  ptomains  and  bacterial  toxalbumoses  set  up  an  endometritis  by 
exciting  round  cell  proliferation  in  the  deeper  layers  of  the  endometrium, 
which  ends  in  a  superficial  necrosis  of  the  overlying  tissues.  The  degree 
of  this  necrosis  depends  in  part  upon  the  contraction  and  retraction  of 
the  uterus.  //  the  uterine  content  is  evacuated  within  a  reasonable  time, 
extensive  necrosis  of  the  endometrium  does  not  result;  but  if  the  tissue 
reaction  continues  and  the  round  tissue  cells  become  banked  up  beneath 
the  endometrium,  the  necrosis  is  extensive.  If  the  necrosis  is  slight,  wq 
have  only  an  intensification  of  the  normal  exfoliation  of  the  mucosa. 
Thus,  with  the  cause  removed,  the  emigration  of  phagocytic  leukocytes 
and  the  formation  of  bactericidal  lochia  tend  to  cleanse  the  uterine  cavity. 
If,  on  the  other  hand,  the  necrosis  is  considerable,  it  may  interfere  with 
the  normal  regeneration  of  the  endometrium.  Hence,  with  the  uterine 
cavity  open  to  the  migration  of  pathogenic  cocci  from  below,  a  mixed 
infection  develops  and  the  patient  may  succumb  from  the  severity  of  the 
absorption;  for  saprophytes  have  been  found  in  the  blood  during  life, 
while  pyogenic  cocci  are  known  to  have  a  definite  penetrability. 

Symptoms. — When  this  condition  exists  within  the  uterus,  there  is 
found  a  definite  train  of  characteristic  symptoms  and  signs.  The  lochia 
remains  bloody,  excessive,  and  fetid,  and  is  frothy  from  an  admixture 
of  gas  bubbles.  An  examination  of  the  secretions  shows  the  presence  of 
saprophytes  and  cocci  of  low  virulence.  The  after  pains  continue  and 
from  time  to  time  a  clot  is  expelled  by  painful  uterine  contraction.  There 
is  a  toxinemia  from  the  absorption  of  the  toxins  produced  by  the  super- 
ficial necrosis ;  this  absorption  from  the  uterine  cavity  causes  an  elevation 
of  temperature  and  a  slight  acceleration  in  the  pulse  rate.  Abdominal 
examination  will  show  that  the  involution  of  the  uterus  is  retarded,  the 
uterus  being  large,  tender  and  more  or  less  relaxed.  Should  the  pelvis 
be  digitally  explored,  the  cervix  will  be  found  open,  swollen  and  eroded, 
and  if  the  gloved  finger  is  passed  into  the  uterine  cavity,  clots  and  necrotic 
debris  are  encountered  and  the  interior  surface  of  the  uterine  cavity  is 
rough  and  shaggy. 

Prognosis. — The  establishment  of  proper  uterine  drainage,  inducing 
retraction  and  contraction  of  the  uterus,  promptly  controls  this  type  of 


8o  PELVIC  INFLAMMATION  IN  WOMEN 

lesion  and  the  fever  subsides.  Hence  it  will  be  argued,  if  expulsion  of 
the  contents  is  followed  by  a  prompt  subsidence  of  the  symptoms,  why 
not  empty  the  uterus  of  this  necrotic  debris  by  surgical  methods? 

Experience  Jias  taught  us  that  any  sort  of  trauma  to  the  delicate  gran- 
ulation ivall,  which  is  confining  the  infection  within  the  uterus,  opens 
avenues  of  extension,  and  that  lateral  prametritis  is  a  constant  sequel  of 
attempts  at  digital  or  instrumental  evacuation.  It  does  no  harm  to  re- 
move sterile  contents,  but  manipulation  always  spreads  infection  when 
th£  content  is  already  infected. 

Coccal  Endometritis. — The  second  type  of  infection  met  with 
within  the  uterus  may  properly  be  called  a  coccal  or  pyogenic  endome- 
tritis; in  this  form  the  infective  bacteria,  the  streptococcus  or  other  pyo- 
cocci have  more  marked  invasive  qualities  and  attack  the  living  tissues, 
and  are  introduced  or  penetrate  into  the  lymphoid  lining,  or  the  myome- 
trium, causing  a  prompt  tissue  reaction  and  producing  a  necrotic  layer 
of  endometrium,  which  resembles  the  false  membrane  of  diphtheria. 

Whether  these  cocci  advance  further  than  the  interior  of  the  uterus 
and  invade  the  lymphatics  and  blood  vessels,  or  remain  confined  within 
the  uterine  cavity,  depends  on  the  completeness  of  development  of  the 
granulation  zone  and  the  virulence  and  the  penetrability  of  the  invading 
bacteria.  If  the  reaction  is  sufficient  to  excite  prompt  resistance  and  the 
leukocytic  barrier  increases  in  thickness,  the  lochia  acquires  bactericidal 
properties,  which  tend  to  sterilize  the  interior  of  the  uterus.  This  ob- 
servation has  been  checked  up  numberless  times  in  our  clinic.  With 
every  puerperal  endometritis  there  is  always  an  associated  metritis; 
this  is  a  defensive  reaction  on  the  part  of  the  myometrium  against  the 
invading  cocci.  In  this  reaction  small  round  tissue  cells,  leukocytes,  fibro- 
blasts, and  polyblasts  are  thrown  out  and  deposited  between  the  muscle 
fibers  and  around  the  gland  tubules,  and  the  further  extension  of  the  cocci 
is  halted.  From  this  primary  endometritis  and  metritis  the  bacterial 
invasion  may  extend  through  the  lymphatics  in  the  uterus  into  the 
surrounding  connective  tissue,  or  to  the  peritoneum  or  through  the  veins 
in  the  placental  site  to  the  blood  stream. 

Since  the  infection  often  begins  at  the  placental  site,  much  depends 
on  its  condition  at  the  time  of  exposure.  If  the  uterus  is  well  retracted 
and  the  sinuses  are  closed,  the  defense  at  this  point  is  effective;  on  the 
other  hand,  if  the  sinuses  are  simply  plugged  with  aseptic  thrombi,  viru- 
lent cocci  like  the  streptococcus  may  infect  these  thrombi  directly  or  pene- 
trate between  the  sinuses  and  enter  the  vessels  from  the  outside  and  thus 
gain  entrance  to  the  circulation. 

Infections  due  to  the  streptococcus  pyogenes  and  the  pyococci  alone 


PUERPERAL  INFECTIONS  8i 

do  not  give  rise  to  fetor,  and  the  interior  surface  of  the  uterus  is  usually- 
smooth  and  not  deeply  necrotic.  As  a  rule  the  bank  of  granulation  tissue 
suffices  to  limit  the  infection  to  the  uterus,  unless  nature's  beneficent 
processes  are  disturbed  by  the  meddling  of  the  accoucheur. 

Symptoms  of  Coccal  Endometritis. — For  the  first  two  or  three 
days  the  puerpera  is  fairly  comfortable,  but  there  is  usually  some  indica- 
tion of  brewing  trouble,  such  as  malaise,  a  higher  pulse  rate  than  is  nor- 
mal, restlessness,  or  pain  in  the  uterus,  or  prolonged  after  pains.  On  the 
third,  fourth,  or  fifth  day  there  is  a  slight  chill  or  chilly  sensation  with  a 
rise  of  temperature,  headache,  anorexia,  and  the  patient  is  conscious  of  a 
feeling  of  heat  over  the  body.  The  pulse  may  range  from  100-140  and 
the  temperature  from  101-104°  F,  depending  on  the  severity  of  the  in- 
fection. The  abdomen  may  become  slightly  distended,  but  there  is  little 
or  no  tenderness  except  over  the  uterus  and  the  involution  of  the  uterus 
is  always  retarded.  If,  however,  the  infection  extends  through  the 
myometrium  to  the  perimetrium,  there  is  tenderness  over  the  uterus  and 
in  both  inguinal  regions.  The  lochia  are  at  first  unaltered,  but  within 
forty-eight  hours  they  have  lost  their  characteristic  qualities  and  become 
serous,  flesh  colored,  or  seropurulent.  The  lochia  are  not  foul,  unless  large 
numbers  of  saprophytes  are  developed.  The  lochia,  however,  have  caus- 
tic infective  qualities  and  the  wounds  in  the  vagina  and  about  the  vulva, 
which  are  bathed  in  them,  are  covered  with  a  pseudodiphtheritic  mem- 
brane. On  physical  examination,  the  cervix  is  closed  and  the  uterus  fairly 
well  retracted,  and  unless  there  has  been  parametrial  extension  its  mo- 
bility is  not  interfered  with.  Were  it  possible  to  make  a  digital  explora- 
tion of  the  interior  of  the  uterus,  it  would  have  been  found  smooth,  and 
the  endometrium  bathed  in  purulent  or  sanguinopurulent  discharge,  free 
from  odor.  Lymphatic  invasion  from  the  cervix  is  shown  in  the  para- 
metritis postica  so  commonly  found  postpartum,  which  is  the  chief  cause 
of  the  backache  experienced  in  the  puerperium.  Extension  of  infection 
from  the  cervix  and  higher  up  in  the  uterus  is  generally  through  the 
lymphatics  in  the  broad  ligaments.  This  extension  produces  a  lateral 
parametritis  or  cellulitis. 

Cellulitis. — Pelvic  cellulitis  or  parametritis  is  an  inflammatory 
reaction  of  the  pelvic  cellular  tissue  to  a  bacterial  invasion.  The  bacteria 
reach  the  parametrium  through  the  lymph  stream,  and  excite  a  tissue 
reaction  in  which  serum,  leukocytes,  and  round  tissue  cells  are  poured  out, 
producing  a  local  inflammatory  swelling. 

Location  of  the  Cellular  Tissue  in  the  Pelvis. — In  order  that 
we  may  better  appreciate  where  to  look  for  these  inflammatory  swellings, 
it  may  be  well  to  briefly  review  the  anatomic  arrangement  of  the  pelvic 


82 


PELVIC  INFLAMMATION  IN  WOMEN 


connective  tissue.  The  pelvic  connective  tissue  lies  under  the  peritoneum 
and  between  the  pelvic  peritoneum  and  the  pelvic  diaphragm.  It  forms 
the  loose  connecting  and  supporting  areolar  structure  between  the  organs 
and  the  pelvic  wall,  and  between  contiguous  viscera  and  soft  structures. 
It  spreads  from  the  uterus  as  a  center,  and  radiates  outward  in  all  direc- 
tions, each  part  reaching  the  pelvic  wall.  It  surrounds  and  supports  the 
blood  vessels,  nerves,  and  lymphatics,  and  forms  thin  sheaths.    It  is  con- 


FiG.  28. — Showing  the  Cellular  Tissue  Lying  Under  the  Pelvic  Peritoneum  and 
Above  the  Levatores  Ani  Muscles. 


densed  into  strong  bands  and  ligaments,   forming  the  aponeurosis  of 
muscles  and  the  ligamentary  attachments  of  the  pelvic  viscera. 

Infections  from  traumatisms  of  the  vagina  and  cervix  chiefly  involve 
this  loose  areolar  and  fatty  tissue,  and  the  infection  is  directed  by  and 
confined  between  the  fascial  sheets  and  ligamentary  planes.  The  sub- 
serous connective  tissue  may  be  traced  across  the  pelvis  from  front  to 
back,  as  this  tissue  is  but  a  continuation  of  the  subperitoneal  layer  of  the 
abdominal  wall.  As  the  peritoneum  passes  off  from  the  abdominal  wall, 
it  is  closely  applied  to  the  fundus  and  posterior  wall  of  the  bladder;  but 
anteriorly,  between  the  bladder  and  the  symphysis,  there  is  a  larger 
areolar  tissue  space  (the  space  of  Retzii).    This  loose  tissue  extends  in  a 


PUERPERAL  INFECTIONS 


83 


thin  layer  along  the  anterior  pelvic  wall  and  over  the  fascia,  covering 
the  obturator  internus  muscle. 

Between  the  posterior  wall  and  the  base  of  the  bladder  and  the  cervix 
uteri  and  vagina,  is  a  loose  connective  tissue  layer  which  allows  the 
bladder  to  be  easily  stripped  off  from  the  front  of  the  uterus  and  vagina. 
There  is  little  loose  cellular  tissue  at  the  fundus  and  down  the  back  of 
the  uterus,  where  the  peritoneal  attachment  is  firm. 

Under  the  peritoneal  covering  of  the  cervix  and  posterior  vaginal 


Fig.  29. — Transverse  Section  Through  Pelvis  at  the  Level  of  the  Internal  Os, 
Showing  How  the  Cellular  Tissue  Spreads  from  the  Uterus  as  a  Center, 
Each  Part  Reaching  the  Pelvic  Wall. 


wall  a  thin  layer  of  connective  tissue  may  be  traced,  having  extensive 
connections  with  the  retroperitoneal  tissue  at  the  back  of  the  pelvis;  this 
continues  backward  to  the  sacrum  in  the  two  uterosacral  folds.  There 
is  also  connective  tissue  at  the  sides  of  the  rectum  and  in  the  mesentery 
of  the  pelvic  colon.  In  tracing  the  cellular  tissue  across  the  pelvis  from 
side  to  side,  we  find  it  extending  from  the  pelvic  wall  to  the  uterus  within 
the  folds  of  the  broad  ligament,  and  from  the  uterus  to  the  opposite  pelvic 
wall.  At  the  base  of  the  broad  ligament  it  is  condensed  into  the  utero- 
pelvic  ligaments,  which  make  one  of  the  main  supports  of  the  uterus. 

A  great  increase  in  the  amount  of  pchnc  cellular  tissue  takes  place 
during  pregnancy;  this  explains  not  only  the  frequency  of  parametritic 


84 


PELVIC  INFLAMMATION  IN  WOMEN 


or  cellulitic  inflammations  after  labor,  but  the  ease  with  which  the  pelvic 
organs  are  separated  in  operative  procedures,  i.e.,  the  evidence  of  lines 
of  cleavage. 

The  lymphatic  channels,  which  drain  the  greater  part  of  the  vagina, 
the  cervnx  and  lower  uterine  segment,  pass  out  along  the  base  of  the  broad 
ligament,  and  are  supported  by  this  arbor  of  cellular  tissue.  These  fol- 
low the  course  of  the  uterine  vessels  to  the  hypogastric  and  iliac  glands. 


Fig.  30. — Sagittal  Section  Showing  the  Relation  of  the  Pelvic  Cellular  Tissue 
TO  the  Bladder  and  the  Rectum. 


The  lymphatics  of  the  fundus  and  upper  part  of  the  body  of  the  uterus 
follow  the  ovarian  vessels  in  the  infundibulopelvic  ligament  to  the  glands 
at  the  bifurcation  of  the  aorta  and  the  lumbar  group.  Lymph  channels 
also  run  in  the  uterosacral  ligaments  to  the  sacral  glands,  and  through 
the  round  ligaments  to  the  inguinal  glands. 

Etiology. — The  majority  of  cases  of  cellulitis  are  due  to  infection 
by  the  streptococcus  pyogenes.  The  staphylococcus  and  bacillus  coli,  and 
occasionally  the  gonococcus,  are  found  in  combination,  but  the  strepto- 
coccus is  the  chief  infecting  agent  of  cellular  tissue. 

The  severity  of  the  infection  depends  on  the  virulence  of  the  infect- 


PUERPERAL  INFECTIONS  85 

ing  organism,  and  the  individual  resistance  of  the  patient,  rather  than 
the  variety  of  the  organisms.  It  has  not  been  proven  that  the  gonococcus 
can  by  itself  produce  primary  pelvic  cellulitis,  neither  does  an  uncom- 
plicated gonorrhea  give  rise  to  the  same  inflammation  and  abscess  for- 
mation seen  in  a  streptococcus  infection. 

The  most  common  avenue  of  entrance  is  through  injuries  to  the  cer- 
vix and  vaginal  vault  during  labor;  for,  besides  the  general  softening  of 
the  tissues  and  enlargement  of  the  connective  tissue  spaces,  and  the  in- 
creased vascularity  due  to  pregnancy,  there  is  a  direct  bruising  of  the 
parts  by  labor,  all  of  which  favor  infection.  The  amount  of  cellular  tis- 
sue in  this  particular  region  is  considerable,  and  the  chief  lymphatic 
channels  draining  it  are  found  at  the  base  of  the  broad  ligament. 

The  cervix  and  surrounding  tissues  are  subject  to  the  greatest  trauma, 
consequently  the  tissue  resistance  here  is  lowest ;  furthermore,  lacerations 
at  these  points  open  into  extensive  cellular  spaces.  Even  trivial  injuries 
may  act  as  the  points  of  ingress,  but  as  a  rule  there  is  the  history  of  an 
instrumental  delivery,  manual  or  bag  dilatation,  or  a  dry  labor  with  fre- 
quent vaginal  examinations.  The  chances  of  infection  are  greater  under 
these  circumstances.  On  the  other  hand,  this  form  of  inflammation  is 
comparatively  rare  after  abortion,  as  the  cervical  tissues  are  not  subjected 
to  such  a  degree  of  trauma;  hence  tubal,  rather  than  parametrial  com- 
plications with  peritoneal  extension  are  the  usual  course.  This  is  ac- 
counted for  by  the  fact  that  the  chance  of  injury  during  the  passage  of  a 
small  ovum  is  less,  and  the  amount  of  connective  tissue  is  also  less  than 
at  full  term. 

Operations  on  both  the  pregnant  and  non-pregnant  uterus,  which  in- 
volve opening  up  of  the  connective  tissue  planes,  are  frequently  the  cause 
of  postoperative  cellulitis.  As  illustrative  of  this,  amputation  of  the 
cervix  and  hysterectomy  by  the  Wertheimer  method  are  frequently  fol- 
lowed by  large  parametrial  exudates. 

Pathology. — The  organisms  invade  the  lymphatic  channels  and  by 
their  presence  and  the  toxins  they  produce  excite  a  hyperemia,  which  is 
followed  by  an  effusion  of  protective  serum,  and  a  hurried  migration  of 
leukocytes  into  the  soft  areolar  tissue,  which,  with  the  deposition  of 
small  round  cells,  make  up  the  exudate.  This  increases  the  tissue  bulk 
and  gives  rise  to  a  soft  swelling,  which  later  becomes  hard  from  the  for- 
mation of  a  more  fibrinous  exudate.  This  exudate  is  generally  limited 
at  first  to  the  base  of  the  broad  ligament  on  the  involved  side.  As  the 
exudate  is  poured  out,  it  usually  follows  the  line  of  least  resistance  in  the 
cellular  tissue  between  the  fascial  sheets  forward  and  outward  to  the  an- 
terolateral pelvic  wall  and  iliac  fossa,  or  backward  along  the  uterosacral 


86 


PELVIC  INFLAMMATION  IN  WOMEN 


folds,  lifting  the  posterior  layer  of  the  peritoneum.  The  fibrinous  de- 
posit which  is  thrown  into  the  pararectal  and  prevertebral  connective  tis- 
sues, fixes  and  displaces  the  uterus  and  rectum,  and  more  or  less  oblit- 
erates the  portio,  holding  the  pelvic  organs  in  a  hard,  sensitive  mass; 
or,  the  exudate  may  spread  forward  at  the  base  of  the  bladder,  and  so 
reach  the  anterior  pelvic  and  abdominal  walls. 

Clinically,  we  have  found  that  the  exudate  may  spread  in  almost 
any  direction  along  the  cellular  tissue  planes.  It  may  be  unilateral  or 
bilateral,  most  frequently  the  former,  or  it  may  spread  around  the  cervix 


Fig.  31.— Exudate  into  the  Lateral  Parametrial  Tissues,  Displacing  the  Uterus 
AND  Obliterating  the  Fornices  and  Vaginal  Portio. 

from  side  to  side  obliterating  the  vaginal  portio,  leaving  the  os  as  a  mere 
dimple  in  the  vaginal  vault;  or  the  bacteria  may  follow  an  unanatomic 
course,  even  passing  through  muscle  or  fascia,  in  which  case  the  exudate 
may  be  found  in  locations  where  it  is  least  expected. 

Von  Rosthorn  has  classified  pelvic  exudates  in  the  cellular  tissues 
in  a  most  practical  way,  showing  their  origin  and  their  usual  course  of 
extension ;  his  classification  is  as  follows  : 

I.  Those  which  come  from  bacterial  invasion  of  cervical  tears  are 
usually  lateral,  horizontal  exudates  located  in  the  base  of  the  broad  liga- 
ments, and  have  a  tendency  to  spread  to  the  side  walls  of  the  pelvis  and 
around  the  cervix. 


PUERPERAL  INFECTIONS  87 

2.  Where  the  infective  extension  comes  through  the  lymphatics  of  the 
uterus,  usually  from  an  endometritis.  The  exudates  occur  as  high  intra- 
ligamentous infiltrations,  beginning  near  the  uterine  comua.  forming 
exudative  tumors,  rounded  above  with  a  tendency  to  unfold  the  broad 
ligaments,  and  extend  into  the  iliac  fossa. 

3.  Exudates  into  the  retrocervical  connective  tissues  from  infective 
cervicitis.  These  spread  posteriorly  along  the  uterosacral  ligaments,  occa- 
sionally involving  the  sacro-iliac  joints,  or  sink  down  into  the  connective 
tissue  of  the  rectovaginal  septum. 

4.  Exudates  in  the  pericervical  tissues  spreading  toward  the  sides  of 
the  pelvis,  along  and  about  the  ureters. 

5.  Exudates  anterior  to  the  bladder  which  tend  to  spread  up  the 
abdominal  wall  behind  the  recti,  forming  abscesses  in  the  abdominal 
wall,  frequently  due  to  the  migration  of  the  colon  bacillus  from  the 
adherent  intestinal  masses. 

The  most  common  is  the  lateral  exudate  extending  from  the  side  of 
the  uterus  to  the  bony  pelvic  wall  and  then  anteriorly,  raising  the  peri- 
toneum upward  and  appearing  as  a  hard  tender  mass  above  Poupart's 
ligament.  Rarer  extensions  are  those  travelling  posteriorly  to  the  sacro- 
iliac joints,  and  retroperitoneal  extension  upward  toward  the  region  of 
the  kidney. 

The  writer  has  also  seen  extensions  through  the  sacrosciatic  foramen 
into  the  thigh,  with  abscesses  posterior  to  the  trochanter,  and  along  the 
infundibulopelvic  ligament  to  the  psoas  muscle. 

In  a  recent  case  the  bacterial  invasion  extended  through  the  broad 
ligament,  through  the  cellular  tissue  in  the  hilum  of  the  ovarv*.  and  in- 
fected its  stroma  with  a  resulting  abscess.  Coincidentally.  the  infection 
passed  through  the  sacrosciatic  foramen  and  formed  an  abscess  just 
posterior  to  the  head  of  the  femur.  Cut  de  sac  drainage  and  incision 
posterior  to  the  trochanter  temporarily  controlled  her  sepsis,  but  not 
until  the  ovan,-  with  the  contained  abscess  was  removed  did  the  patient 
recover  her  health. 

The  exudate  varies  in  its  extent  and  consistence,  depending  on  the 
virulence  of  the  germ  and  the  resistance  of  the  patient.  In  mild  cases 
there  may  be  nothing  but  a  simple  inflammatory  edema,  and  again  in 
the  more  virulent  types  of  cellular  infection  the  exudative  process  is 
limited  to  a  serous  and  poorly  defined  cellular  infiltration,  for  the  bac- 
teria quickly  pass  through  the  lymphatics  to  the  peritoneum  or  into  the 
blood  stream.  Fortunately  for  the  protection  of  the  individual,  in  most 
cases  there  is  an  adequate  protective  tissue  reaction  zcith  the  formation  of 
large  exudates.     Section  through  these  masses  shows  the  lymph  vessels 


88 


PELVIC  INFLAMMATION  IN  WOMEN 


thickenedT  tortuous  and  beaded,  and  a  yellowish  or  whitish  pus  exudes 
from  numberless  minute  openings.  The  lymphatic  chains  are  surrounded 
with  exudate,  giving  them  a  glistening,  glassy,  moist  appearance.  The 
veins  are  often  thrombotic,  either  from  primary  infection,  or  they  may 
become  secondarily  infected  and  the  thrombi  may  undergo  puriform 
degeneration,  the  debris  breaking  up  and  getting  into  the  circulation, 
forming  infected  emboli. 

As  the  exudate  increases  in  amount  the  blood  supply  is  increased.  This 
is  especially  apparent  on  the  venous  side,  and  later  as  cicatricial  tissue 


Fig.  32. — As  the  Exudate  Organizes  and  the  Scar  Tissue  Contracts,  the  Uterus 
Is  Drawn  Toward  the  Side  of  the  Exud.\te, 


forms  and  the  scars  shrink;  the  arteries  are  kinked  and  varicosities  occur 
in  the  veitis,  while  the  ganglia  and  nerves  may  become  pinched  in  the 
contracting  cicatrices.  This  explains  the  pain  and  the  frequency  of  pelvic 
varicosities  in  patients  who  give  a  history  of  an  infected  puerperium. 
Coincident  with  the  pouring  out  of  exudate  into  the  cellular  tissues  in 
the  broad  ligaments  subperitoneally,  there  is  an  edema,  and  necessarily 
the  pelvic  peritoneum  takes  part  in  the  inflammation  and  throws  out  an 
exudate  upon  its  surface,  which  causes  the  tubes  and  ovaries  to  become 
matted  together  and  adherent  to  the  broad  ligaments,  uterus,  or  the 
intestines,  clinically  giving  the  impression  of  large  exudate  masses. 

Consequently  it  may  be  stated  that  parametritis  ahcays  excites  some 


PUERPERAL  INFECTIONS  89 

degree  of  perimetritis.  This  inflammatory  exudate  may  undergo  com- 
plete absorption,  or  may  go  on  to  suppuration.  If  absorption  occurs, 
there  is  always  some  pathology  which  permanently  remains.  When  an 
exudate  suppurates,  the  pus  is  discharged  externally  or  becomes  encap- 
sulated, limiting  the  mobility  of  the  pelvic  viscera  and  occasioning  pre- 
menstrual pain. 

In  the  milder  infections  with  a  serofibrinous  exudation  complete  reso- 
lution usually  takes  place.  Large  masses  of  fibrinous  exudate  may  com- 
pletely disappear  without  leaving  much  edema  or  tissue  damage.  There 
are,  however,  always  varicosities  of  the  pelvic  veins  to  tell  the  story  of 
the  intense  venous  engorgement,  which  was  necessary  to  supply  the  pro- 
tective exudate  needed  in  nature's  attempt  to  bury  the  infecting  invaders 
(Fig.  32). 

In  the  more  severe  infections  suppuration  may  occur  with  the  for- 
mation of  an  abscess  cavity,  or  necrotic  areas  may  appear  in  various 
parts  of  the  exudate,  and  these  become  converted  into  pus.  Commonly, 
there  is  one  cavity  which  results  from  the  conjunction  of  several  pus 
foci ;  occasionally  the  entire  pelvis  may  be  riddled  with  abscesses.  Mul- 
tiple foci  of  suppuration  are  commonly  of  thrombotic  origin  and  really 
belong  to  a  different  class  from  the  simple  cellulitic  abscess.  These 
large  abscesses,  dependent  upon  their  proximity  to  one  of  the  hollow 
organs,  are  apt  in  the  course  of  from  twenty  to  seventy  days  to  point, 
and  unless  they  are  evacuated  by  operative  measures,  to  break  into  the 
rectum,  bladder,  vagina  or  on  the  skin  above  Poupart's  ligament  or 
into  the  peritoneal  cavity;  and  if  the  pus  is  completely  evacuated,  the 
cavity  closes  rapidly.  Unfortunately,  when  these  abscesses  open  spon- 
taneously, it  is  seldom  at  the  most  dependent  point  or  there  may  be  other 
or  more  remote  foci ;  hence  the  pus  is  not  completely  evacuated  and  the 
septic  process  may  be  kept  up  for  weeks  or  months.  Sometimes  the 
abscess  does  not  open,  and  nature  cures  the  condition  by  encapsulating 
the  pus.  The  wall  of  the  abscess  is  thickened  and  becomes  firm  with 
fibrous  tissue,  while  the  more  fluid  part  of  the  pus  is  absorbed.  Such  a 
tumor  may  persist  in  the  pelvis  for  years,  gradually  shrinking  in  size. 
The  writer  has  watched  several  of  such  cases  over  a  period  of  years. 

It  is  important  to  note  that  the  encapsulated  germs  do  not  always  lose 
their  virulence,  hut  may,  on  the  occasion  of  subsequent  traumatism  or 
operation,  break  out  zvith  increased  virulence  and  cause  a  bactericuda. 
This  was  shown  in  one  of  the  writer's  patients,  who  went  through  a  long 
postpartum  cellulitis,  in  which  an  immense  exudative  mass  gradually  and 
slowly  absorbed  and  diminished  in  size,  but  never  completely  disappeared. 
Three  years  later  she  came  into  the  hospital  pregnant,  and  gave  birth 


go  PELVIC  INFLAMMATION  IN  WOMEN 

spontaneously  to  a  small  baby  without  any  vaginal  examination  being 
made.  The  placenta  was  also  expelled  spontaneously;  she  died  eighty 
hours  later  of  a  streptococcic  bacteriemia,  hemolytic  streptococci,  two 
hundred  colonies  to  the  cubic  centimeter  were  found  in  the  blood. 
Autopsy  showed  that  a  cervical  tear  had  been  reopened  and  the  solution 
of  tissue  had  passed  through  an  encapsulated  pus  cavity  in  the  left  para- 
metrium. 

Unless  there  has  been  considerable  trauma  of  the  soft  tissue,  it  is 
remarkable  to  see  how  little  scar  tissue  is  left  after  these  connective 
tissue  abscesses  heal.  On  the  other  hand,  when  there  have  been  extensive 
lacerations  and  trauma  of  the  soft  parts,  as  tears  through  the  cervix, 
lower  uterine  segment,  and  into  the  base  of  the  broad  ligament,  the. 
woman  is  left  with  a  permanent  displacement  of  the  uterus,  owing  to  the 
contraction  of  the  cicatricial  tissue. 

The  pelvic  cellulitis  may  be  complicated  by  femoral  thrombosis  and 
phlegmasia  alba  dolens,  though  we  are  of  the  belief  that  the  more 
severe  cases  should  be  regarded  as  a  septic  thrombosis  with  an  accom- 
panying cellulitis;  it  is  conceivable  also  to  believe  that  an  immense  exu- 
date may  of  itself  be  sufficient  to  cause  compression  of  the  pelvic  veins 
and  produce  edema  of  the  leg  or  thigh.  This  is  so  especially,  when  the 
exudate  is  in  the  anterior  portion  of  the  pelvis,  between  the  peritoneum 
and  the  pelvic  bones. 

Chronic  pelvic  cellulitis  is  but  an  extension  of  chronic  inflammation 
and  is  usually  found  to  be  associated  with  infected  cervical  lacerations. 
It  is  seen  in  the  posterior  uterosacral  cellulitis  and  the  lateral  parametritis 
so  constant  in  chronic  endocervicitis.  We  believe  that,  next  to  endo- 
metritis, cellulitis  is  the  most  frequent  pathological  lesion  found  in  puer- 
peral infection.  Seven  to  eleven  per  cent  of  all  gynecological  cases  have 
a  coexisting  parametritis. 

Symptoms. — In  the  mildest  form  evidences  of  previous  cellular  in- 
fection are  commonly  found  during  gynecological  examination  in  the 
form  of  a  thickening  or  scar  in  one  of  the  fornices,  drawing  the  cervix 
over  to  one  side.  This  may  have  caused  no  noticeable  symptoms  during 
the  puerperium  or  there  may  have  been  a  slight  rise  in  temperature,  and 
a  little  local  tenderness  in  one  or  the  other  iliac  fossa,  but  of  such  brief 
duration  as  not  to  have  directed  the  attention  of  the  attendant  to  the 
pelvis. 

In  the  severer  grades  there  is  usually  a  history  of  a  traumatic  labor 
with  instrumental  delivery,  or  of  a  dry  labor  where  frequent  vaginal 
examinations  have  been  made  or  pituitary  extract  was  given  to  hasten  the 
labor.    Then,  on  the  third  or  fourth  day  postpartum,  the  patient  com- 


PUERPERAL  INFECTIONS  91 

plains  of  pain  in  one  or  the  other  inguinal  regions  and  the  temperature 
rises. 

Nearly  always  the  symptoms  of  endometritis  precede  those  of  paror- 
metritis,  and  the  early  symptoms  of  the  local  lesion  are  frequently  masked 
by  a  variable  degree  of  toxemia,  manifested  by  pyrexia,  acceleration  of 
the  pulse  rate,  headache,  anorexia,  malaise,  etc.  It  is  usually  possible 
to  determine  the  time  when  the  infection  passes  from  within  the  confines 
of  the  uterus  and  reaches  the  broad  ligament.  A  chill  or  chilliness,  feb- 
rile reaction,  increase  in  the  pulse  rate,  and  the  occurrence  of  marked  local 
pain  are  constant  symptoms;  these,  with  the  general  manifestations  of 
the  febrile  state,  such  as  headache,  muscle  soreness,  anorexia,  sleepless- 
ness and  restlessness  make  up  the  symptom  complex.  All  movements 
cause  pain  in  the  affected  side.  Nausea  and  vomiting  are  generally  ab- 
sent in  cellular  infections,  unless  the  process  involves  the  overlying  peri- 
toneum. 

The  degree  of  localization  is  determined  by  the  degree  of  virulence 
of  the  infecting  organism  and  the  local  and  general  resistance  of  the 
patient's  tissues.  Traumatism  and  hemorrhage  definitely  reduce  this  re- 
sistance. 

As  a  rule,  there  is  a  prompt  tissue  reaction  at  the  seat  of  infection, 
demonstrable  as  an  exudate  which  is  poured  into  the  cellular  tissues, 
except  in  the  case  of  infections  from  hemolytic  bacteria,  when  there  is 
little  or  no  local  reaction,  hence  less  demonstrable  lesion. 

The  symptoms  of  an  acute  localized  cellulitis  may  appear  three  or 
four  days  after  delivery,  or  may  be  delayed  as  late  as  the  second  week. 
The  fever  which  may  be  present  soon  after  delivery  will  either  have 
diminished  for  a  time,  only  to  increase  again  with  the  development 
of  the  local  lesions,  or,  if  there  has  been  little  or  no  fever  in  the  first  week, 
a  rising  temperature  with  morning  remissions  will  mark  the  pouring  out 
of  the  exudate  into  the  cellular  tissue.  The  local  inflammation  may  be 
ushered  in  with  rigor,  but  repeated  chills  are  uncommon  in  cellular  inflam- 
mation. The  pulse  rate  rises  and  falls  with  the  temperature;  a  per- 
sistently high  pulse  rate  is  uncommon  in  parametritis. 

Pain  is  present  in  one  or  the  other  lower  abdominal  quadrant,  but 
it  is  not  such  a  marked  feature  as  in  pelvic  peritonitis.  It  is  most  severe 
when  the  effusion  develops  rapidly.  It  is  aggravated  by  movement ;  often 
it  extends  down  the  thigh  of  the  affected  side  or  up  into  the  loin.  In 
slowly  developing  exudates  pain  may  be  entirely  absent. 

When  the  exudate  extends  into  the  iliac  fossa,  the  leg  on  that  side  is 
generally  drawn  up  to  relax  the  tension  on  the  psoas  and  iliacus  muscles, 
as  the  sheaths  and  connective  tissue  bundles  of  these  are  involved  in  the 


92  PELVIC  INFLAMMATION  IN  WOMEN 

inflammatory  process.  Defecation  and  micturition  may  be  painful  when 
the  exudate  is  contiguous  to  the  rectum  or  bladder.  Diarrhea  with  the 
passage  of  mucus  with  the  stool,  and  the  signs  of  cystitis,  indicates 
extension  of  the  inflammatory  process  to  the  rectal  and  vesical  walls. 

In  addition  to  the  local  discomfort  or  pain  and  pyrexia,  the  general 
symptoms  of  cellulitis  are  those  of  a  toxemia,  i.e.,  sleeplessness,  restless- 
ness, anorexia,  thirst,  headache  and  constipation.  The  tongue  is  coated, 
but  the  severe  oral  changes  are  generally  absent  and  the  general  health 
little  affected  except  in  those  prolonged  cases  which  go  on  to  suppura- 
tion, or  where  there  has  been  extensive  blood  loss  at  the  time  of  delivery. 
The  temperature  gradually  subsides  in  the  course  of  a  week  or  ten  days, 
only  to  rise  again  on  some  pelinc  manipulation,  which  squeezes  the  toxins 
out  of  the  limiting  exudate.  It  must  be  remembered  that  an  exudate  is 
always  a  conservative  process,  which  tends  to  limit  bacterial  extension. 

Physical  Signs. — On  examination,  some  evidence  of  uterine  infec- 
tion is  generally  found;  the  uterus  may  be  tender  and  larger  than  is 
justified  by  the  period  of  the  puerperium,  the  lochia  may  be  profuse, 
offensive  or  purulent  discharge  and  lacerations  of  the  cervix  or  vagina 
are  frequently  present. 

An  exudate,  extending  from  the  cervical  rent  in  the  base  of  the  broad 
ligament,  is  not  usually  found  for  some  days  after  the  onset  of  the 
symptoms.  At  first  the  edema  and  infiltration  of  the  tissues  give  only  a 
feeling  of  tenderness  and  greater  resistance  in  one  or  both  sides  of  the 
vaginal  vault,  but  as  the  effusion  becomes  more  fibrinous  in  character, 
a  definite,  hard,  unyielding  mass,  running  out  laterally  from  the  uterus 
or  forward  to  the  anterior  pelznc  wall,  blending  intimately  with  the  uterus, 
will  be  recognized.  This  mass  becomes  harder  and  more  fixed,  causing 
depression  of  the  vaginal  vault  on  that  side  or  surrounding  the  cervix 
like  a  collar,  effacing  the  portio.  The  uterus  is  immobile  and  either  set 
in  this  mass  of  exudate,  which  blends  intimately  with  it,  or  is  displaced 
toward  the  unaffected  side. 

Recto-abdominal  examination  will  show  the  pouch  of  Douglas  and 
the  posterior  part  of  the  pelvis  free  from  mass,  and  permit  the  palpation 
of  the  smooth  hard  posterior  surface  of  the  broad  ligament.  As  the 
mass  increases  in  size,  it  passes  forward  to  the  cellular  tissues  beneath 
the  reflection  of  the  peritoneum  on  the  anterior  abdominal  wall,  and 
forms  a  broad  band  of  induration  running  parallel  to  Poupart's  ligament, 
or  it  may  extend  upward  into  the  loin  and  reach  the  kidney. 

Differential  Diagnosis  of  cellular  inflammations  presents  great 
difficulty;  especially  is  it  difficult  to  differentiate  these  exudates  from  the 
intraperitoneal  masses  so  commonly  found  as  a  complication  of  inflamed 


PUERPERAL  INFECTIONS  93 

appendages.  The  clinical  history  does  much  toward  suggesting  the 
diagnosis. 

Primary  cellulitis  is  always  a  sequel  of  infected  labor  or  operative 
procedures,  which  open  into  the  cellular  tissues  of  the  pelvis,  hence  unless 
such  a  history  is  obtainable,  pelvic,  exudative  masses  must  have  their 
origin  in  some  infective  focus  in  the  uterine  appendages. 

Severe  abdominal  pain  and  tenderness  with  rigidity  of  the  abdominal 
wall,  especially  if  accompanied  by  distention  and  difficulty  in  obtaining 
an  action  of  the  bowels,  clearly  point  to  a  peritoneal  infection.  Acute 
pain  and  abdominal  tenderness  may  generally  be  taken  as  indicative  of 
peritoneal  involvement.  The  fever  is  usually  more  marked  in  cellulitis 
than  in  peritonitis,  while  the  relation  of  the  pulse  rate  to  the  temperature 
is  higher  in  peritonitis  than  in  cellulitis. 

The  differentiation  between  cellulitis  and  peritonitis  by  physical  signs 
is  very  difficult  in  the  acute  stage  of  inflammation,  because  both  the  peri- 
toneum and  cellular  tissues  are  involved.  Frequently  a  positive  diagnosis 
cannot  be  made  until  all  of  the  acute  symptoms  have  subsided. 

The  distinctive  shape  of  the  inflamed  uterine  appendages  is  only  met 
with  in  the  chronic  swellings  in  the  "cold  stage."  The  principal  points 
in  differentiation  are : 

1.  The  history. 

2.  Pelvic  cellulitis  is  more  often  unilateral,  while  peritonitis  is  com- 
monly a  bilateral  affection. 

3.  In  pelvic  cellulitis  the  mass  is  at  the  base  of  the  broad  ligament 
and  extends  forward  toward  the  anterior  pelvic  wall  and  intimately 
blends  with  the  uterus.  In  pelvic  peritonitis  the  mass  is  found  behind 
the  broad  ligament  and  in  the  cul  de  sac  of  Douglas;  the  exudate  is  in 
the  posterior  quadrant. 

4.  The  presence  of  a  fluid  exudate  in  the  pouch  of  Douglas  which 
pushes  the  uterus  forward  makes  a  peritoneal  infection  certain.  A  hard 
ring  around  the  rectum,  on  rectal  exploration,  suggests  a  peritoneal 
rather  than  a  cellular  inflammation. 

Septic  thrombosis  of  the  pelvic  veins  may  occasionally  give  rise  to 
a  tender  circumscribed  swelling  or  a  thickened  cord,  extending  from  the 
uterus  outward  toward  the  pelvic  wall.  Some  exudation  into  the  peri- 
venous cellular  tissue  always  surrounds  these  thrombosed  veins  and  so 
adds  to  the  size  of  the  swelling.  High  fever  of  a  remittent  type,  with 
rigors  and  sweats  and  other  pyemic  symptoms,  is  generally  present.  The 
small  size  of  the  pelvic  mass,  with  the  serious  character  of  the  general 
symptoms,  is  characteristic  of  thrombophlebitis. 

Prognosis. — Localized  cellulitis  terminates  in  resolution  or  suppura- 


94  PELVIC  INFLAMMATION  IN  WOMEN 

tion ;  the  exudative  protection  is  so  complete  that  recovery  is  the  rule,  for 
the  surrounding  exudate  confines  the  toxins.  If  the  mass  becomes  harder, 
smaller  and  insensitive,  and  examination  or  manipulation  fails  to  cause 
a  rise  of  temperature  or  increase  in  the  leukocyte  count,  we  may  con- 
clude that  time  will  accomplish  complete  absorption,  leaving  but  one 
sequela,  i.e.,  pelvic  varicosities. 

Evening  elevation  of  temperature  with  remissions  or  intermissions, 
increased  size  and  sensitiveness  of  the  mass,  and  an  increased  polymor- 
phonuclear percentage,  suggests  suppuration.  The  diagnosis  is  positive 
when  fluctuation  can  be  determined.  When  the  abscess  has  been  opened 
and  good  drainage  established,  the  fever  subsides  and  at  once  the  general 
condition  improves.  The  rapidity  with  which  the  toxic  symptoms  abate 
is  characteristic  of  an  uncomplicated  cellulitic  abscess.  Some  displace- 
ment and  permanent  fixation  of  the  pelvic  organs  will  result  from  cica- 
trization in  cases  of  extensive  suppuration.  The  most  serious  conse- 
quences are  those  due  to  a  spread  of  infection  to  other  structures.  Infec- 
tion of  the  large  venous  plexuses  in  the  pelvis,  with  septic  thrombosis 
and  pyemia  may  occur,  but  fortunately  is  rare.  The  writer  has  seen  but 
one  such  case  in  a  very  extended  experience. 

Rupture  of  the  cellulitic  abscess  into  the  peritoneal  cavity  is  also 
very  unusual,  but  rupture  of  abscesses  in  the  paravesical  space  does  occur 
into  the  bladder,  giving  rise  to  cystitis,  which  at  times  is  intractable. 
Pyelitis  and  pyelonephritis  are  possible  complications. 


CHAPTER  V 

PUERPERAL  INFECTIONS— (Continued) 

Infections  of  the  veins — Thrombophlebitis  of  the  femoral  or  of  the  saphenous  veins — 
Puerperal  pyemia — Treatment  of  the  infections  of  the  femoral  and  pelvic  veins — 
Radical  treatment — Bacteriemia — Avenues  of  entrance — Prognosis  in  puerperal 
infections — Treatment  of  puerperal  infections — Parametritis  and  perimetritis — 
Pelvic  peritonitis — Operative  measures — Infusions  of  citrated  blood — Gas  bacillus 
infection. 

INFECTIONS  OF  THE  VEINS 

There  are  tzvo  chief  types  of  infection  which  attack  the  veins: 

(a)  Thrombophlebitis  of  the  femoral  vein  or  of  the  saphenous  vein. 

(b)  Puerperal  pyemia. 

Thrombophlebitis  of  the  Femoral  or  Saphenous  Vein. — This  type 
of  infection  is  characterized  by  edematous  swelling  of  one  or  both  lower 
limbs,  without  severe  constitutional  disturbances,  except  a  moderate 
pyrexia. 

In  puerperal  pyemia,  septic  emboli  are  deposited  in  distant  parts 
of  the  body  and  repeated  rigors  occur,  which  are  followed  by  marked 
temperature  rise  and  pulse  flights,  with  grave,  frequently  fatal,  toxemia. 

Clinical  Course. — Simple  thrombosis  of  the  saphenous  or  femoral 
veins,  or  of  the  iliac,  is  attended  with  edema  of  the  lower  extremity, 
beginning  at  the  foot  and  extending  to  the  trunk.  The  onset  is  usually 
sudden,  beginning  during  the  second  week  of  the  puerperium,  though 
the  occurrence  of  the  pain  and  local  edema  is  commonly  preceded  by 
tardy  involution  of  the  uterus,  the  persistence  of  the  red  lochia,  and  a 
slight  hut  continuous  elevation  in  the  evening  temperature.  Coincident 
with  the  occurrence  of  local  pain,  there  is  an  increase  or  a  recurrence 
of  the  temperature.  The  pain  is  located  in  the  foot  or  in  the  calf 
or  in  the  groin,  and  the  edema,  which  begins  in  the  foot,  rapidly  involves 
the  whole  limb.  The  skin  is  cool,  translucent,  and  mottled,  or  marbled 
with  distended  veins.  The  pain  and  temperature  gradually  subside  in  a 
week  or  ten  days.  The  left  limb  is  more  commonly  affected  than  the 
right,  but  in  one  third  of  the  cases  both  limbs  are  involved. 

Beside  the  general  edema  of  the  limb,  the  glazed  stretched  appear- 
ance of  the  skin,  and  the  marked  enlargement  of  the  superficial  veins, 
there  may  be  fullness,   induration,   and  tenderness  at  some  one  point 

95 


96  PELVIC  INFLAMMATION  IN  WOMEN 

along  the  course  of  the  involved  vein.  This  focus  is  most  commonly 
found  in  the  groin  or  over  the  calf  of  the  leg  below  the  popliteal  junction. 

The  writer  l>elieves  that  these  thrombophlebitic  lesions  are  always 
the  result  of  infection.  This  view  is  concurred  in  by  DeLee,  McLean, 
and  others.  No  case  has  ever  been  observed  in  which  there  has  not 
been  some  elevation  of  temperature  before  the  occurrence  of  the  local 
lesion. 

Symptoms. — Many  cases  of  sudden  death,  during  the  puerperium, 
from  embolism,  are  preceded  by  mild  febrile  symptoms,  rapid  pulse,  or 
local  symptoms  which  indicate  that  infective  disease  of  some  kind  exists 
in  the  pelvis.  With  the  exception  of  these  rare  accidents,  the  disease  as  a 
rule  runs  a  favorable  course,  the  fever  keeps  a  low  level,  the  pain  dis- 
appears, and  then  gradually  the  swelling  subsides,  the  general  health,  ap- 
petite and  sleep  are  but  little  disturbed,  and  recovery  takes  place  in 
from  two  to  six  weeks.  The  edema,  however,  persists  for  some  time, 
especially  the  edema  of  the  leg  and  foot,  which  may  appear  toward 
the  end  of  the  day,  for  months. 

A  more  serious  condition  is  thromho phlebitis  of  the  pelvic  and  crural 
veins,  zchich  is  but  an  oiitzvard  extension  of  the  infection  of  the  uterine 
veins,  part  of  a  general  pyemic  process.  In  this  form  of  thrombophlebitis, 
the  pain  and  swelling  of  the  leg  are  preceded  by  the  signs  of  endometritis 
and  pelvic  inflammation,  or  the  original  intrapelvic  symptoms  may 
have  been  overlooked  or  gone  unnoticed  until  extension  to  the  crural  veins 
has  occurred.  There  may  be  an  initial  chill,  which  is  followed  imme- 
diately by  thrombotic  localization  in  the  limb;  this  occurs  usually  after 
the  eighth  day,  or  as  late  as  the  twentieth.  The  woman  experiences  pain 
in  the  groin  or  in  the  calf  of  the  leg.  The  swelling  is  first  noticed 
in  Scarpa's  triangle  and  the  labium.  The  groin  is  commonly  the  site  of 
greatest  pain,  and  the  thrombosed  femoral  may  be  palpated  as  a  swollen 
sensitive  cord,  due  to  the  associated  periphlebitis,  as  it  passes  under 
Poupart's  ligament.  This  is  easily  demonstrated  in  thin  women.  The 
upper  thigh  is  immensely  swollen  and  has  a  white  opalescent  or  some- 
what yellowish  tint;  is  hot  and  sensitive;  frequently  the  tension  is  so 
great  that  the  tissues  will  not  pit  on  pressure.  Within  a  few  hours,  and 
always  within  a  day  or  two,  the  whole  limb  is  involved;  the  leg  and 
foot  become  edematous,  but  not  infiltrated.  The  constitutional  symp- 
toms may  or  may  not  be  ushered  in  with  a  chill,  but  fever  is  ahvays 
present  and  the  patient  shows  signs  of  a  severe  illness,  as  of  a  pyemic 
process. 

Both  limbs  may  be  involved  one  after  another,  for  this  type  of 
phlebitis  is  but  an  extension  of  a  septic  thrombosis  of  the  pelvic  veins, 


PUERPERAL  INFECTIONS  97 

which  has  crept  out  through  the  pampiniform  plexus  to  the  obturator  or 
hypogastric  veins,  thence  to  the  ihac,  and  then  to  the  femoral.  There 
is  always  a  periphlebitis,  which  adds  to  the  tissue  block  and  thus  increases 
the  areas  of  infiltration.  The  fever  is  irregular,  with  remissions,  but 
does  not  intermit.  The  pulse  is  high  and  the  course  of  the  disease  pro- 
tracted. It  may  be  weeks  or  even  months  before  the  infiltration  of  the 
tissues  disappears  and  the  venous  obstruction  subsides.  The  thrombosis 
may  even  extend  to  the  arteries  and  terminal  gangrene  result. 

Commonly  an  inflammation  or  stasis  of  the  lymphatic  channels 
accompanies  the  inflammation  of  the  veins,  for  the  process  has  an  intra- 
pelvic  origin;  the  infection  spreads  out  of  the  pelvis  and  down  the 
leg,  so  that  the  surrounding  cellular  tissue  is  solid,  with  infiltrated 
lymph. 

Every  pelvic  phlebitis  is  attended  zuith  more  or  less  cellular  indanv- 
mation  and  may,  because  of  the  proximity  of  the  peritoneum,  excite  a 
local  peritonitis;  consequently  the  cellular  and  peritonitic  inflammation 
may  mask  the  true  lesion  in  the  vein. 

Puerperal  Pyemia. — This  form  of  puerperal  infection  is  far  more 
common  than  is  generally  recognized.  Lea,  from  his  extensive  post- 
mortem studies,  claims  that  it  is  responsible  for  from  thirty  to  fifty  per 
cent  of  all  deaths  from  infection. 

In  nearly  all  cases  intra<-nterine  manipidations  have  preceded  its  onset, 
i.e.,  careless  treatment  of  placenta  previa,  or  postpartum  hemorrhage,  or 
a  curettage  for  uterine  infection  has  been  recently  done. 

The  writer  has  recently  seen  three  cases  of  direct  infection  of  the 
placental  site,  following  long  dry  labors,  without  any  intra-uterine  man- 
ipulation, except  frequent  vaginal  examinations.  This  confirms  the  ob- 
servations of  Slemons,  that  long  dry  labor  reduces  the  endothelial  re- 
sistance of  the  amniotic  cells,  and  allows  infective  bacteria  to  penetrate 
the  placenta  and  enter  the  placental  site;  hence  all  cases  in  which  there 
is  an  interpartum  temperature  should  be  viewed  with  suspicion. 

Clinically  the  condition  is  characterized  by  repeated  rigors,  with 
sharp  elevations  and  marked  remissions  of  temperature.  The  rise  of 
temperature  immediately  follows  the  rigor,  and  this  is  succeeded  by  a 
sudden  remission  and  profuse  sweat.  Anemia  and  wasting  rapidly  de- 
velop, owing  to  the  rapid  destruction  of  the  cellular  elements  of  the  blood. 
The  pulse  rises  with  the  temperature,  but  has  not  the  proportionate  fall. 
The  prostration  is  extreme,  though  the  patient  may  feel  fairly  well  and 
b€  able  to  take  food  in  the  intervals  between  rigors.  The  red  cell  de- 
struction is  rapid,  the  hemoglobin  falling  10-50  points  in  a  period  of  a 
few  days.     There  is  little  or  no  leukocytosis.     Emboli  may  locate  in 


98  PELVIC  INFLAMMATION  IN  WOMEN 

the  lung,  pleura,  endocardium,  and  brain.  The  physical  signs  are  not 
definite,  nor  are  they  usually  marked.  Involution  may  be  arrested,  but 
the  abdomen  is  generally  negative,  unless  the  condition  is  complicated  by 
parametria!  or  peritoneal  infections  as  well.  Commonly  there  is  a  history 
of  retarded  involution;  the  uterus  is  relaxed,  the  lochia  profuse,  there  are 
painful  uterine  contractions,  and  a  slight  evening  temperature  before  the 
extension  into  the  veins  occurs.  Occasionally  there  is  a  slight  tenderness 
on  deep  pressure  over  the  course  of  the  ovarian  or  external  iliac  veins. 

Vaginal  examination  may  reveal  by  careful  palpation  a  small  slightly 
tender  swelling,  either  high  up  in  the  ovarian  region,  due  to  phlebitis  of 
the  ovarian  plexus  of  veins,  or  at  the  base  of  the  broad  ligament,  when 
the  uterine  veins  are  thrombosed.  Williams  claims  that  the  thrombosed 
veins  may  be  palpated  as  tender  "worm-like"  masses  in  the  broad  liga- 
ment, by  recto-abdominal  touch.  An  extensive  clinical  experience  con- 
vinces us  that  the  diagnosis  must  be  made  from  the  clinical  symptoms,  not 
by  physical  signs;  as  the  tactile  sense  is  seldom  able  to  differentiate  the 
thromlx)sed  veins  from  coincident  parametric  and  peritoneal  lesions. 
Signs  of  ulcerative  endocarditis  may  l>e  made  out  and  appear  relatively 
early.  About  half  of  the  fatal  cases  show  this  complication.  Septic  em- 
bolic pneumonia  of  the  patchy  type  is  an  almost  constant  postmortem 
finding,  though  it  is  seldom  detected  during  life. 

The  prognosis  is  always  grave;  death  occurs  in  from  one  to  three 
weeks  from  general  asthenia  and  toxemia,  though  the  patient's  life  may 
be  suddenly  cut  short  by  sudden  death  from  pulmonary  emlx)lism.  Less 
than  twenty  per  cent  spontaneously  recover.  Beach  reports  a  case  of 
recovery  after  eighty-six  days  in  a  woman  w'ho  had  repeated  small  trans- 
fusions. Beck  and  the  writer  have  seen  four  recoveries  in  seven  typical 
cases,  as  a  result  of  the  expectant  plan  of  treatment,  in  which  fresh  air 
and  small  repeated  blood  transfusions  were  the  only  therapeutic  measures 
used. 

Those  patients  in  whom  there  are  embolic  abscesses  in  the  super- 
ficial tissues,  seem  to  develop  the  greatest  resistance.  One  of  the  author's 
cases,  which  recovered  after  109  days  of  fever,  developed  abscesses  in 
both  arms,  both  legs,  and  in  the  lungs ;  but  throughout  her  leukocyte  count 
never  fell  Ijelow  16,000. 

Treatment  of  Infections  of  the  Femoral  and  Pelvic  Veins. — 
In  the  management  of  thrombophlebitis  of  the  femoral  or  saphenous 
veins  the  treatment  is  largely  symptomatic,  for,  until  a  collateral  cir- 
culation is  esta1>lished,  swelling  of  the  limb  must  necessarily  persist. 
As  has  already  Ijeen  stated  in  discussing  the  pathology,  when  the  femoral 
vein  is  involved,  there  is  usually  a  periphlebitis  in  the  cellular  tissues  of 


PUERPERAL  INFECTIONS  99 

Scarpa's  triangle.  This  effectually  blocks  the  deep  return  circulation 
from  the  limb,  consequently  the  foot,  leg  and  thigh  become  enormously 
swollen  and  the  patient  complains  of  intense  stretching  pain  in  the 
thigh,  due  to  the  extreme  tissue  tension. 

Proper  elevation  of  the  limb,  to  faz'or  the  return  circulation,  is 
the  basic  fundamental  in  the  treatment.  Heat  and  elastic  support  con- 
tribute somewhat  to  the  patient's  comfort.  Our  plan  has  been  to  elevate 
the  leg  and  thigh,  haznng  the  leg  slightly  flexed  on  pillows,  the  limb  is 
then  wrapped  from  the  toes  to  the  groin  in  cotton  batting,  which  is 
held  in  place  by  a  firmly  applied  stockinet  bandage;  this  gives  elastic 
support  and  yet  sufficient  pressure,  to  favor  the  establishment  of  a  return 
circulation.  Codein  or  morphin  in  small  and  repeated  doses  must  be 
used  for  the  relief  of  the  pain.  In  addition  to  this  it  may  be  necessary 
to  relieve  the  pain  due  to  the  cellulitis  in  the  groin  by  the  application 
of  cold ;  this  is  done  by  placing  an  ice  bag  on  the  groin  over  the  femoral. 

The  constitutional  symptoms,  which  are  always  pronounced  during 
the  active  thrombus  formation  and  the  invasion  of  the  thrombus  with 
cocci,  are  treated  by  general  supportive  measures,  i.e.,  the  copious  in- 
gestion of  water,  evacuation  of  the  bowels  by  daily  enemata,  and  stimu- 
lation of  the  leukocytic  reaction  by  the  administration  of  leukocytic  ex- 
tracts. The  pyrexia  needs  no  medical  treatment,  as  it  is  but  an  index 
of  the  tissue  reaction,  which  is  attempting  to  localize  and  check  further 
bacterial  extension. 

After  a  week  or  ten  days  the  remissions  in  temperature  become  more 
marked  and  the  swelling  and  edema  in  the  leg  gradually  tend  to  sub- 
side. The  temperature  should  be  normal  for  at  least  ten  days  before 
the  patient  is  allowed  to  use  the  leg,  and  she  should  never  be  permitted 
to  get  up  and  about  without  proper  elastic  support,  as  the  swelling  in  the 
terminal  portion  of  the  limb  will  persist  for  months  after  a  collateral 
circulation  has  been  established ;  for  the  collateral  circulation  is  made 
by  gradual  enlargement  of  the  superficial  veins,  which  have  not  the 
natural  tissue  support  of  the  deeper  vessels. 

Occasionally  the  tissues  involved  in  the  periphlebitis  in  Scarpa's 
triangle,  in  the  popliteal  space,  or  the  calf  of  the  leg,  may  suppurate. 
Should  this  occur,  it  is  well  to  allow  the  abscess  to  point  before  it  is 
incised,  otherwise  we  are  apt  to  have  an  indolent  ulcer  result,  which 
has  little  or  no  tendency  to  heal,  owing  to  the  poorly  nourished  sur- 
rounding tissues. 

When  the  diagnosis  of  a  thrombophlebitis  of  the  pelvic  veins  has 
been  made,  two  plans  of  treatment  have  been  advocated,  (i)  the  ex- 
pectant and  (2)  the  radical.    We  believe  that  thrombophlebitis  is  a  con- 


roo  PELVIC  INFLAMMATION  IN  WOMEN 

servative  process,  an  evidence  of  nature's  effort  to  localize  the  infective 
organism  in  the  veins  by  the  formation  of  a  blood  dot  to  block  its  path. 
Bacteria  liquefy  the  thrombus  and  then  advance  through  it.  When  again 
there  is  a  reaction  on  the  part  of  the  blood  to  this  advance,  more  clot  is 
formed  and  another  temporary  block  is  established.  As  this  is  the  fact, 
it  is  easily  appreciated  that,  whether  the  bacterium  advances  or  re- 
mains localized,  will  depend  on  the  character  of  the  bacterium,  its 
virulency,  and  the  resistance  of  the  patient's  blood  stream.  The  chill  is 
the  index  and  the  evidence  of  its  advance;  the  fez'er  is  but  the  symbol 
of  tissue  reaction;  the  intermission  in  the  fever,  the  sign  of  the  tem- 
porary check.  If  the  leukocytic  resistance  and  the  fibrin  forming  ele- 
ments of  the  blood  are  sufficient,  the  lumen  of  the  vessel  becomes  obliter- 
ated with  an  organized  clot  and  the  temperature  gradually  subsides. 
Upon  the  other  hand,  if  the  cellular  elements  of  the  blood  are  deficient, 
or  the  bacterium  is  hemolytic,  the  infecting  organism  is  bound  to  pass 
through  the  fibrinous  obstruction  and  reach  remote  points  by  the  blood 
stream. 

Unfortunately,  the  leukocytic  resistance  is  always  lozv  in  thrombo- 
phlebitis, the  white  cell  count  will  seldom  be  found  to  be  more  than  ten 
thousand,  and  the  red  cells  and  hemoglobin  are  progressively  diminished ; 
hence,  in  the  expectant  treatment,  knowing  what  is  necessary  for  nature 
to  do  in  order  to  control  the  advance  of  the  infection,  we  can  simply  aid 
it  by  general  supportive  treatment. 

It  has  been  our  practice  to  treat  these  patients  with  fresh  air  a:nd 
sunshine,  having  their  beds  removed  to  the  roof,  and,  if  possible,  having 
them  sleep  in  the  air.  This  materially  improves  their  appetite  and 
digestion,  so,  during  their  remissions  in  temperature,  they  are  able 
to  take  food  and  digest  it.  The  kidney  elimination  is  stimulated  by  the 
copious  ingestion  of  water  and  by  enteroclysis,  using  a  glucose  and  bi- 
carbonate of  soda  solution,  and,  when  the  temperature  rises,  their 
resistance  is  maintained  by  the  use  of  lactose  in  fruit  juices. 

In  addition  to  this  plan  of  general  sustaining  treatment,  we  have 
found  that  repeated  small  transfusions  of  blood  (300-350  c.cm.  at  a  time) 
gradually  increase  the  cellular  elements  in  the  blood  stream  and  thus 
offer  a  better  tissue  reaction  to  the  bacterial  invasion  of  the  clot.  These 
transfusions  are  given  of  citrated  blood  at  three  or  four  day  intervals. 
A  full  blood  count  is  taken  before  and  after  each  transfusion  and,  not 
until  the  red  cells  and  hemoglobin  show  a  definite  improvement,  and 
are  able  to  maintain  this  improvement  during  the  periods  between  the 
transfusions,  are  the  blood  injections  omitted.     If  the  patient  is  to  have 


PUERPERAL  INFECTIONS  loi 

a  favorable  outcome,  it  soon  becomes  apparent  that  the  leukocyte  in- 
crease is  maintained  and  the  red  cells  rapidly  increase. 

Radical  Treatment. — The  radical  treatment  consists  of  ligation  and 
excision  of  the  infected  ovarian  and  hypogastric  veins.  This  was 
first  done  by  Freund  in  1897.  In  1902  Trendelenburg  reported  five 
operations  with  an  improved  technic,  demonstrating  the  advantage  of 
his  posture  in  exposing  the  field  of  operation;  and  recently  Miller,  of 
New  Orleans,  has  published  an  extensive  article  on  the  status  of  liga- 
tion in  thrombophlebitis.  His  review  included  all  the  reported  cases 
to  191 7,  with  a  corrected  mortality  from  Hgation  of  32.9  per  cent. 

Unfortunately,  the  diagnosis  as  to  the  exact  location  of  the  throm- 
bosed vein  is  difficult  to  make  clinically.  Williams  claims  that,  by 
manual  palpation,  the  thrombosed  veins  may  be  recognized  as  hard, 
sensitive  cords  in  the  base  of  the  broad  ligament;  this  has  not,  however, 
been  our  experience,  for  it  is  usual  for  the  ovarian  vein,  rather  than  the 
uterine,  to  be  the  seat  of  the  thrombosis,  and  hence  bimanual  palpation 
will  commonly  fail  to  locate  the  thrombosed  veins,  and  when  masses  have 
been  palpated  in  the  base  of  the  broad  ligament,  operation  or  autopsy 
has  usually  shown  them  tD  be  of  a  parametritic  character.  The  diagnosis, 
however,  is  easily  made  on  the  history  and  clinical  picture  and  low 
leukocyte  count. 

It  would  seem  from  Miller's  analysis  that,  if  the  ovarian  veins 
alone  are  involved,  the  outlook  for  operation  is  favorable,  if  done  at 
the  proper  moment.  When  both  the  ovarian  and  the  hypogastrics  are 
involved,  the  outlook  is  hopeless.  We  are  not  at  all  sure  that  ligation 
will  show  better  results  than  transfusion,  for  the  best  results  of  the 
advocates  of  ligation  have  been  attained  in  the  subacute  and  chronic 
cases,  which,  in  our  experience,  are  the  cases  which  get  well  spontan- 
eously. Again,  it  has  been  our  experience  that  there  is  more  or  less  peri- 
vascular inflammation  in  the  cellular  structures  surrounding  the  veins, 
as  well  as  some  complicating  peritonitis.  //  the  operation  is  to  he  a 
success,  it  must  he  done  in  the  case  mJiicJi  is  free  from  lymphatic  or 
peritoneal  infection.  Hysterectomy  defeats  the  purpose  of  confining  the 
bacterial  advance  to  the  thrombus  already  formed.  This  statement  is 
supported  theoretically  and  by  the  clinical  experience  of  most  observers. 

Technic. — The  technic  is  relatively  simple  to  the  experienced  abdom- 
inal operator.  With  the  patient  in  a  high  Trendelenburg  posture,  the 
abdomen  is  opened  by  a  long  median  incision,  the  pelvis  packed  off  from 
the  general  cavity,  and  the  sigmoid  lifted  toward  the  median  line.  The 
parietal  peritoneum  is  now  divided  to  the  outer  side  of  the  sigmoid,  and, 
with  blunt  dissection,  the  pelvic  veins  may  be  easily  and  completely  ex- 


I02  PELVIC  INFLAMMATION  IN  WOMEN 

posed.  The  thrombosed  vein  is  isolated,  ligated  above  and  below  the 
thrombus,  and  the  vein  severed.  It  is  not  necessary  to  excise  the  inter- 
vening portion.  A  similar  procedure  is  done  on  the  opposite  side.  In 
our  cases  we  have  ligated  both  internal  iliacs  close  to  their  junction  with 
the  common,  as  well  as  both  ovarians.  By  this  extensive  exclusion  the 
best  results  have  been  obtained.  The  reflected  peritoneum  is  then  brought 
into  place  and  sutured  and  the  abdomen  closed  without  drainage.  The 
fundamental  principle  is  to  disturb  the  pelvis  as  little  as  possible  by 
manipulation. 

Bacteriemia. — Bacteriemia  means  the  presence  of  bacteria  in  the 
blood.  It  is  an  acute  infectious  disease,  produced  most  frequently  by  the 
streptococcus  pyogenes,  or  the  staphylococcus.  These  cocci  with  their 
toxins,  produce  changes  in  the  blood,  destroying  the  red  cells  as  well  as 
the  leukocytes,  and  cause  degenerative  changes  in  the  organs  through 
which  they  pass,  notably,  the  heart,  the  liver  and  the  kidneys. 

Besides  the  streptococcus  and  the  staphylococcus,  which  are  the  most 
common  invaders  of  the  blood  stream,  the  pneumococcus,  the  bacillus 
pyocyaneus,  the  gonococcus,  the  bacillus  aerogenes  capsulatus,  and  several 
anaerobic  bacilli  have  been  found  in  blood  cultures. 

Avenues  of  Entrance. — In  postabortal  and  puerperal  infections 
entrance  is  gained  into  the  blood  stream  by  two  routes :  first,  by  lym- 
phatic extension,  second,  by  direct  invasion  of  the  venous  radicles  and 
sinuses.  Each  mode  of  invasion  proceeds  in  a  definite  manner,  and  the 
clinical  pictures  produced  differ  so  much  that  it  is  generally  possible  to 
make  a  differential  diagnosis.  Occasionally,  however,  the  pictures  are 
indistinct  and  differentiation  is  impossible. 

The  lymphatic  form  develops  from  an  endometritis,  the  infection  in 
turn  extending  to  the  myometrium  and  the  para-uterine  lymphatics; 
but  it  is  so  virulent  that,  instead  of  exciting  an  active  reaction  in  the 
parametrium  and  para-uterine  lymph  spaces,  the  reaction  is  simply  a 
serous  exudate  with  local  edema  and  the  infection  proceeds  directly  into 
the  blood  stream  or  through  the  lymphatics  to  the  peritoneum,  exciting 
an  acute,  purulent  peritonitis. 

On  the  other  hand,  the  vascular  form  almost  invariably  begins  as  a 
uterine  phlebitis,  primarily  as  an  infection  of  the  thrombi  in  the  placental 
site,  with  an  extension  of  the  infected  thrombi  into  the  veins.  From 
these  infected  thrombi  the  bacteria  enter  and  multiply  in  the  blood,  and 
subsequently  locate  in  distant  organs,  such  as  the  pleura,  the  lung,  the 
endocardium,  and  the  brain.  Occasionally  the  thrombi  may  suppurate, 
but  this  is  not  common  in  streptococcemia.  However,  as  a  result  of 
such  suppuration,  bits  of  infected  fibrin  or  actual  pus  may  get  loose,  and 


PUERPERAL  INFECTIONS  103 

be  carried  away  by  the  blood  stream  to  remote  parts  of  the  body,  and 
there  locate  and  cause  local  abscesses;  the  lung,  kidneys,  and  the  brain 
are  the  points  most  frequently  reached  by  these  infected  emboli. 

In  blood  stream  infections  the  local  pathological  reaction  is  inconsid- 
erable; consequently  the  local  symptomatology  is  insignificant,  for, 
whether  the  bacteria  enter  the  blood  stream  via  the  lymphatics,  or  via 
the  veins,  their  transit  is  so  rapid,  and  the  tissue  reaction  caused  so  insig- 
nificant, that  appreciable  local  lesions  must  necessarily  be  absent. 

For  the  entrance  of  bacteria  into  the  blood  stream  there  must  be  a 
puerperal  wound,  which  is  inoculated  by  bacteria.  This  may  be  at  any 
point  in  the  genital  tract,  the  vulva,  vagina,  the  cervix,  or  in  the  placental 
site.  DeLee  states  that  even  a  tear  of  the  frenulum  may  afford  access, 
through  which  a  virulent  streptococcus  may  reach  the  blood  stream. 
Here,  as  in  other  puerperal  lesions,  the  activity  of  the  process  depends 
on  the  virulence  of  the  coccus  and  the  resistance  of  the  patient.  Women 
who  have  had  severe  postpartum  hemorrhage,  or  have  been  toxic,  prior 
to  their  delivery,  offer  less  resistance  to  coccal  invasion  than  women 
whose  antepartum  or  interpartum  period  has  been  less  depleting. 

In  the  lymphatic  varieties  of  bacteriemia  the  findings  at  autopsy  are 
constant  and  typical.  ( i )  Endometritis  gangrenosa  or  metritis  desiccans 
(Garrigues),  in  which  the  whole  tract  is  covered  with  a  grayish  sloughing 
diphtheroid  exudate.  (2)  Parametritis  and  lymphangitis,  the  lymph 
vessels  at  the  sides  of  the  uterus  being  filled  with  purulent  fluid  which 
exudes  from  the  cut  surface.  The  connective  tissues  may  be  infiltrated 
and  edematous,  and  this  cellulitis  may  spread  so  fast  and  so  far  as  to 
justify  the  name  which  Virchow  gave  it,  "Erysipelas  puerperalis  malig- 
num  internum."  The  changes  in  the  parametria  may  be  simply  a  serous, 
infectious  edema,  or  necrosis  may  occur,  and  a  real  phlegmon  result.  (3) 
Pelvic  peritonitis,  then  general  peritonitis.  (4)  If  the  patient  lasts  long 
enough,  pleuritis  and  pericarditis.  (5)  Gastritis,  enteritis,  and  colitis. 
(6) With  the  general  pathology  of  acute  infectious  disease,  i.e.,  swollen 
spleen,  fatty  degeneration  and  cloudy  swelling  of  the  muscle  fibers,  espe- 
cially of  the  heart,  and  cloudy  swelling  of  the  liver  and  kidneys.  Bac- 
teria in  immense  numbers  are  found  in  the  minute  capillaries  of  these 
organs.  (7)  The  findings  of  metastases  in  the  lungs,  heart,  brain,  joints, 
and  connective  tissues. 

In  the  vascular  forms  of  bacteriemia  the  lymphatics  are  not  involved 
at  all,  or  if  so,  to  a  very  decidedly  less  extent.  The  veins  of  the  placental 
site  are  filled  with  large  thrombi,  which  are  swarming  with  bacteria. 
The  bacteria  erode  the  endothelial  lining  of  the  vessel,  fibrin  is  there- 
fore deposited  on  the  eroded  surface,  and  a  clot  occludes  the  lumen;  and 


104  PELVIC  INFLAMMATION  IN  WOMEN 

this  process  advances  through  the  venous  plexuses  of  the  broad  Hga- 
ment  into  the  ovarian  and  iHac  veins,  even  to  the  vena  cava. 

From  the  surface  of  these  thrombi,  bacteria  are  Hberated  into  the 
blood  stream,  and  if  they  are  strong  enough  to  multiply  in  it,  a  fatal 
bacteriemia  may  result.  If  the  bacteria  are  less  virulent,  the  process 
becomes  more  chronic,  the  thrombi  undergo  puriform  softening,  and 
solid  bits  of  thrombus  or  droplets  of  pus  break  loose  and,  floating  in  the 
blood  stream,  lodge  in  distant  parts  of  the  body,  setting  up  new  foci  of 
suppuration,  which  is  actually  a  condition  of  pyemia. 

Symptoms. — A  period  of  incubation  of  from  one  to  three  days  usu- 
ally precedes  the  outbreak  of  the  severe  symptoms.  Occasionally  threat- 
ening prodromata  appear  within  a  short  time  after  the  inoculation,  and 
the  woman  becomes  seriously  sick  and  may  die  within  thirty-six  hours. 
Ordinarily  the  prodromal  stage  is  manifested  by  the  signs  and  symptoms 
of  the  local  process,  from  the  site  of  which  the  bacterial  invasion  of  the 
blood  has  extended. 

In  the  consideration  of  the  pathology,  we  have  shown  how  bacteria 
may  enter  the  blood  stream  from  a  local  ulcer,  through  the  lymphatics, 
or  from  an  endometritis  or  parametritis,  or  by  way  of  the  placental  site 
with  infection  of  its  thrombi.  It  is,  however,  frequently  impossible  to 
determine  when  or  how  the  germs  get  into  the  blood.  Since  our  bac- 
teriologists have  been  using  anaerobic  methods,  we  have  frequently  been 
able  to  cultivate  the  streptococcus  from  the  blood  where  the  diagnosis  of 
a  purely  local  lesion  has  previously  been  made. 

The  following  syndrome  is  indicative  of  a  serious  bacteriemic  infec- 
tion, though  it  is  claimed  that  absorption  of  toxins  in  large  amounts, 
will  produce  similar  symptoms;  this  I  cannot  verify  from  personal  ex- 
perience. Blood  invasion  is  ushered  in  by  a  severe  chill,  lasting  from 
five  to  thirty  minutes;  during  the  chill  the  skin  is  pale,  the  face  is  pinched 
and  the  lips  and  fingers  cyanotic;  the  temperature  rises  rapidly  to  103- 
105°  F.  and  the  pulse  increases  at  once  above  120,  varying  from  130  to 
160.  At  first  the  pulse  is  full  and  bounding,  but  it  soon  becomes  soft 
and  compressible,  for  the  toxins  in  the  blood  weaken  the  heart  muscle. 
Owing  to  the  rapid  destruction  of  the  red  blood  corpuscles,  the  oxygen 
carr}'ing  power  of  the  blood  is  diminished,  and  the  patient  exhibits 
marked  pallor,  the  finger  tips  are  cyanotic  and  the  respirations  are  hur- 
ried, and  the  woman  looks  profoundly  sick.  The  white  blood  cells  show 
no  tendency  to  increase,  owing  to  the  intense  and  overwhelming  intoxi- 
cation. Owing  to  the  rapid  production  of  toxins,  the  non-striated  muscle 
in  the  heart  and  intestinal  tract  becomes  toneless,  due  to  cloudy  swelling, 
^nd  as  the  heart  weakens,  the  blood  pressure  falls  and  there  is  more  and 


PUERPERAL  INFECTIONS  los 

more  tympany  from  intestinal  paresis.  This  further  embarrasses  the 
heart  and  respiration. 

Malaise  becomes  a  prominent  factor  early  in  the  attack,  the  woman 
appears  prostrated  and  apprehensive  of  impending  danger.  Headache 
and  sleeplessness  are  constantly  complained  of  and  even  though  the 
patient  has  no  pain,  she  does  not  sleep.  This  symptom  is  particularly 
ominous.  The  mind  may  remain  clear  until  near  the  end;  this  how- 
ever is  unusual,  as  a  mild  delirium  is  the  rule.  As  the  endocarditis  de- 
velops the  delirium  becomes  more  marked. 

The  bacteriemic  symptoms  may  occur  alone,  or  be  succeeded  by  the 
symptoms  and  signs  of  a  purulent  peritonitis,  i.e.,  nausea,  vomiting,  and 
pain.  These,  with  the  facies  hippocratica,  show  the  end  is  not  far  dis- 
tant. 

If  the  bacteriemia  has  occurred  as  the  result  of  rapid  lymphatic  in- 
vasion from  a  coccal  endometritis,  local  pelvic  symptoms  may  coexist. 
The  lochia  are  usually  profuse  and  putrid,  the  result  of  a  gangrenous 
endometritis,  though  in  the  severer  types  the  lochia  may  be  scant  and 
free  from  odor.  The  odor  is  pungent  and  the  puerperal  wounds  become 
necrotic.  Signs  of  peritonitis,  such  as  tenderness,  tympany,  spreading 
rigidity,  ileus,  etc.,  begin,  and  if  the  patient  lives  long  enough  the  picture 
becomes  one  of  virulent  peritonitis.  When  this  occurs  the  temperature 
may  go  down,  but  the  pulse  always  rises  and  the  tongue  becomes  dry.  A 
peculiar  sickening,  fruity  odor  is  noticed  about  the  patient  and  while 
the  patient  feels  easier,  the  objective  symptoms  grow  worse.  The  body 
is  cold,  the  face  flushed,  and  beads  of  cold  perspiration  stand  out  on  the 
forehead,  while  the  nose,  lips  and  ears  are  of  a  leaden  gray.  Death  usu- 
ally occurs  in  coma  preceded  by  pulmonary  edema. 

The  disease  lasts  for  from  two  to  ten  days  and  is  especially  virulent, 
if  it  begins  during  labor,  when  the  course  is  usually  short  and  violent. 
Eruptions  on  the  skin  resembling  scarlatina  and  measles  occasionally  oc- 
cur. This  has  nothing  in  common  with  true  scarlatina,  though  the  preg- 
nant woman  is  not  immune  from  the  disease.  It  is  really  a  toxic  strep- 
tococcic erythema.  There  is  no  angina  and  this  helps  in  making  the 
differentiation. 

The  Prognosis  in  Puerperal  Infection. — The  estimated  death 
rate  from  postpartum  septic  infections  varies  from  five  to  thirty  per  cent. 
Unfortunately,  it  is  difficult  to  obtain  reliable  statistics,  owing  to  the 
fact  that  many  of  the  deaths  are  reported  as  pneumonia,  pulmonary  em- 
bolus, endocarditis,  and  so  forth.  It  is  true  that  the  chief  causes  of  death, 
judging  from  autopsy  findings,  are  septic  foci  in  the  lungs,  malignant 
endocarditis,  pulmonary  embolism,  and  septic  peritonitis  but  these  condi- 


«•«??'* 

Ky 


io6  PELVIC  INFLAMMATION  IN  WOMEN 

tions  are  secondary  to  the  primary  septic  focus  in  the  pelvis.  Occasion- 
ally, in  cases  of  severe  infection,  no  gross  lesions  can  be  found  at  autopsy 
and  it  must  be  assumed  that  the  death  is  due  to  the  severity  of  the  toxi- 
nemia  or  bacteriemia. 

Postabortal  infections  are  less  liable  to  be  attended  by  fatality,  for 
tubal  and  pelvic  peritoneal  lesions,  rather  than  lymphatic  and  blood  stream 
infections,  commonly  follow  upon  an  infected  abortion,  and  further- 
more, because  the  uterus  is  well  within  the  pelvic  cavity,  isolation  of  the 
infection  by  peritoneal  adhesion  is  more  likely. 

The  prognosis  in  the  particular  case  depends  (i)  on  the  site  and 
extent  of  the  lesion,  (2)  on  the  form  and  virulence  of  the  organism, 
and  finally  (3)  upon  the  resistance  of  the  patient. 

Broadly  speaking,  vulvovaginal  infections,  uncomplicated  endome- 
tritis putrida,  cellulitis,  femoral  thrombosis,  and  pelvic  peritonitis  give 
the  most  favorable  prognosis,  while  it  must  be  admitted  that  excessive 
blood  loss  during  or  following  labor  materially  reduces  the  patient's  re- 
sistance and  contributes  to  the  severity  of  any  of  these  lesions.  Fatal 
results  from  any  of  the  foregoing  are  unusual. 

Vulvovaginal  infections,  although  sometimes  attended  by  high  tem- 
perature and  copious  discharge,  usually  terminate  in  complete  recovery. 
The  remaining  scars  seldom  cause  more  severe  trouble  than  to  limit  the 
mobility  of  the  contiguous  organs  and  occasion  dyspareunia. 

Putrid  endometritis  usually  makes  a  rapid  recovery  after  proper 
uterine  drainage  has  been  established;  occasionally,  however,  extension 
of  the  septic  process  may  take  place  through  the  placental  site  or  through 
the  lymphatics  and  a  pelvic  thrombophlebitis  or  bacteriemia  develop.  It 
is  better  therefore,  in  this  condition,  to  give  a  guarded  prognosis. 

Cellulitis  generally  terminates  in  recovery  with  or  without  suppura- 
tion. The  course  of  the  disease  is  often  prolonged,  but  if  the  process 
is  entirely  confined  to  the  cellular  tissue,  the  possibility  of  future  preg- 
nancy is  not  impaired ;  on  the  other  hand  a  pelvic  peritonitis,  which  also 
runs  a  long  course,  commonly  ends  in  resolution  or  a  pelvic  abscess ;  in 
either  case  the  tul:>es  are  impaired  by  the  results  of  peritubal  inflamma- 
tion, and  sterility  and  dysmenorrhea  are  common  sequelae. 

In  femoral  thrombosis  (thrombophlebitis),  while  the  prognosis  is 
usually  favorable,  the  possible  danger  of  pulmonary  embolism  must  be 
constantly  borne  in  mind.  Embolism  occurs  in  from  five  to  ten  per  cent 
of  cases  of  thrombosis  and  ends  in  death  more  often  than  in  recovery. 
It  happens  most  frequently  in  the  first  ten  days  after  the  thrombosis  ap- 
pears, but  the  danger  of  embolism  is  not  passed  until  the  temperature  has 
remained  normal  for  at  kast  three  week§.    Femoral  throm.bo§i§  may  ter- 


PUERPERAL  INFECTIONS  107 

minate  in  the  pyemic  or  more  fatal  form  of  venous  infection.  Marked 
pyrexia,  signs  of  suppuration,  and  accompanying  thrombosis  of  the  pelvic 
veins  are  unfavorable  features.  Varicosities  of  the  extremity  are  a  con- 
stant reminder  of  the  original  pathology. 

In  the  bacteriemic  form  of  puerperal  septic  infection  the  prognosis 
should  always  be  guarded.  Early  onset  after  labor,  severe  general  symp- 
toms, and  an  ascending  or  persistently  rapid  pulse  indicate  a  severe  type 
of  the  disease.  The  degree  of  pyrexia  is  not  such  a  valuable  index  to  the 
virulence  of  the  infection  as  are  the  pulse  rate  and  the  blood  pressure, 
but  generally  speaking,  a  persistent  pyrexia  is  always  serious  for  this 
impairs  the  woman's  resistance.  About  60  per  cent  of  the  severer  types 
of  bacteriemia  end  fatally,  usually  from  toxemia  or  general  peritonitis. 
The  milder  types,  which  are  commoner,  usually  recover ;  however,  a  mild 
type  may  develop  into  the  virulent  type. 

Pyemia  has  a  high  mortality.  Bumm  states  that  the  mortality  is  83 
per  cent.  Unfortunately  we  have  no  accurate  way  of  estimating  the 
cases.    According  to  Miller,  this  mortality  is  too  high. 

The  Treatment  of  Puerperal  Infections. — Broadly  speaking, 
we  may  divide  the  treatment  of  puerperal  infections  into  the  prophylactic 
and  ciirative.  Preventive  measures  play  such  an  important  role  and 
so  much  can  be  done  during  pregnancy  and  labor  to  prevent  the  occur- 
rence of  infection,  that  a  more  detailed  discussion  of  the  prophylactic 
measures  seems  justifiable. 

Admitting  that  all  puerperal  infection  is  the  result  of  inoculation  of 
the  puerperal  wound  with  pathogenic  bacteria,  and  that  while  many  of 
these  organisms  have  their  habitat  in  the  genital  tract,  and  may  migrate 
into  the  wounds  of  the  vulva,  vagina,  cervix,  or  uterus,  clinically  we 
know  that  they  are  most  commonly  carried  into  these  wounds  by 
the  hands  or  instruments  of  the  accoucheur.  Naturally,  therefore,  pro- 
phylactic treatment  must  include  the  proper  preparation  of  the  vulvar 
orifice,  sterilization  of  hands  and  instruments,  and  the  education  of  the 
pregnant  woman  in  local  cleanliness  and  marital  abstinence  in  the  later 
weeks  of  pregnancy;  for  it  must  be  realized  that  the  uterine  cavity  and  its 
contents  are  sterile  at  the  time  of  labor  or  abortion,  if  such  labor  or  abor- 
tion is  spontaneous,  until  it  is  contaminated  with  the  bacterial  flora  from 
the  outside.  Generally  speaking,  all  local  infections  such  as  furuncles 
about  the  vulvar,  bartholinitis,  vulvitis,  and  so  forth,  must  be  cured  be- 
fore it  is  safe  to  conduct  a  delivery. 

Crede  claims  that  the  underlying  principles  in  the  conduct  of  an  asep- 
tic delivery  are  (i)  to  lifnit  as  far  as  possible  the  puerperal  wounds  and 
(2)  to  prevent  infection  of  th?  necessary  puerperg,}  wounds;  hence  all 


io8  PELVIC  INFLAMMATION  IN  WOMEN 

cases  should  have  the  vulim  properly  prepared  before  any  vaginal  exami- 
nation, and  no  vulva  is  properly  prepared  unless  the  mdvar  hair  is  re- 
moved. 

The  number  of  internal  examinations  should  be  limited.  In  our  clinic 
we  have  found  that  infection  is  directly  proportionate  to  the  number  of 
vaginal  examinations.  It  is  entirely  possible  to  conduct  the  great  ma- 
jority of  labors  by  abdominal  palpation  and  auscultation,  by  the  use 
of  which  one  can  follow  the  descent  and  rotation  of  the  presenting  part, 
and  from  the  knowledge  thus  gained,  if  used  in  conjunction  with  re- 
peated rectal  examinations,  one  may  obtain  accurate  information  of  the 
rate  of  progress  and  degree  of  cervical  dilatation.  Only  in  case  of  acci- 
dent, such  as  prolapse  of  the  cord  or  hemorrhage  (placenta  previa),  or 
when  the  progress  of  labor  has  been  arrested,  is  it  necessary  to  make 
vaginal  examinations.  When  such  an  internal  examination  is  necessary, 
the  same  aseptic  care  should  be  observed  as  is  practiced  in  entering  the 
abdominal  cavity.  Preservation  of  the  bag  of  waters  is  a  great  safeguard 
against  infection,  particularly  infection  of  the  placental  site,  for  Slemons 
has  shown  that  it  is  possible  in  dry  labors  for  bacteria  to  pass  from  the 
interior  of  the  fetal  sac  directly  through  the  placenta  and  produce  throm- 
bophlebitis in  the  placental  site.  Attempts  to  hurry  labor  by  the  intro- 
duction of  bags,  as  well  as  manual  dilatation  of  the  cervix  or  vaginal  out- 
let, tend  to  increase  the  possibility  of  infection.  Forceps  operations  and 
operative  interference  generally  subject  the  woman  to  increased  trauma 
and  consequent  liability  to  infections. 

In  our  clinic  we  prevent  perineal  and  vaginal  tears  by  a  median  dis- 
cission of  the  perineum ;  this  is  done  just  before  crowning  is  complete.  In 
this  way  we  substitute  an  incised  wound  through  the  median  raphe  for  a 
lacerated  wound,  which  allows  the  levatores  to  retract,  and  this  in  turn 
relieves  the  pressure  on  the  stretched  fascial  sheets  of  the  vagina,  and  thus 
avoids  extensive  vaginal  tears.  These  median  epistomy  incisions  are 
readily  repaired  and,  owing  to  the  slight  trauma  to  the  tissues,  heal 
kindly. 

The  physiological  conduct  of  the  third  stage  is  also  a  great  safeguard 
against  infection,  for  by  allowing  sufficient  time  to  elapse  after  delivery 
for  the  spontaneous  separation  and  expulsion  of  the  placenta,  there  is 
little  likelihood  of  fragments  being  retained.  Manual  removal  and  forced 
efforts  at  Crede  bruise  the  uterus  and  diminish  its  resistance,  thus  in- 
creasing the  susceptibility  to  infection. 

Curative  Treatment. — The  curative  treatment  is  based  on  the  proper 
recognition  of  the  natural  pathology,  zvhich  must  be  given  its  place,  for 
if  we  admit,  and  we  must,  that  the  interior  of  the  uterus  is  a  large  wound 


PUERPERAL  INFECTIONS 


log 


surface  and  is  the  principal  port  of  entry  for  bacterial  invasion,  and  that 
the  interior  of  the  uterus  if  left  to  itself,  undisturbed  by  interference  or 
trauma,  is,  except  in  the  presence  of  the  most  virulent  bacteria,  competent 
to  defend  itself  against  the  invading  organisms,  one  can  readily  see  the 
fruitlessness  and  fallacy  of  intra-uterine  manipulation,  whether  it  be  by 
curettage  or  irrigation. 

In  our  clinic  we  have  not  been  slow  to  take  up  and  try  out  each  of 
the  many  successive  suggestions  which  have  been  made  for  the  treat- 
ment of  primary  puerperal  endometritis,  whether  the  infection  was  of 
the  putrid  or  coccal  type.  The  amount  of  material  at  our  disposal,  in  the 
obstetric  and  gynecological  services  of  the  Long  Island  College,  Metho- 
dist, and  Jewish  Hos- 
pitals, has  afforded 
ample  opportunity  to 
convince  us  that  uterine 
drainage  is  the  chief 
contributing  factor  in 
the  normal  uterine  re- 
action against  bacterial 
invasion.  Our  present 
treatment,  therefore,  is 
along  physiological 
lines,  aiding  and  stimu- 
lating nature's  own 
methods  of  combating 
the  disease. 

This  can  be  done  by 
(i)  postural  drainage  of  the  uterus  and  by  (2)  securing  proper  uterine 
retraction.  Notwithstanding  my  many  unconvinced  colleagues,  the 
Fowler  elevated  trunk  posture,  when  properly  used  and  supplemented 
by  emptying  the  vagina  from  time  to  time,  by  having  the  patient  turn 
over  and  lie  upon  her  abdomen,  the  stimulation  of  uterine  contrac- 
tion and  retraction  by  the  use  of  the  ice  bag  over  the  fundus,  and  the 
administration  of  pituitrin  and  the  ergot  preparations,  does  attain  this 
better  than  any  form  of  intra-uterine  irrigation.  Even  when  we  are  cer- 
tain that  there  is  some  foreign  material  retained  within  the  uterine  cavity, 
the  uterus  is  not  invaded,  for  the  protective  granulation  zone  offers  the 
necessary  protection  against  further  invasion. 

Only  when  repaired  pelvic  structures  show  evidence  of  bacterial  in- 
oculation are  any  active  measures  employed;  in  such  a  case,  the  sutures 
are  removed  and  the  gaping  wounds  swabbed  with  the  tincture  of  iodin. 


Fig.  33. 


-Fowler  Position  by  Blocks  Under  Head  of 
Bed. 


1 10  PELVIC  INFLAMMATION  IN  WOMEN 

Removal  of  the  sutures  usually  affords  all  the  drainage  the  wounds 
need. 

In  order  to  give  the  reader  a  more  systematic  review  of  the  methods 
employed  and  the  reasons  for  their  employment,  we  will  consider  the 
treatment  under  the  headings  of  the 

1.  Local, 

2.  General, 

3.  Specific,  and 

4.  Surgical  measures. 

(i)  Local  Measures. — Theoretically  it  would  seem  that  it  was 
rational  to  remove  clots,  decidua,  membranes,  and  placental  fragments, 
which  serve  as  a  pabulum  for  bacteria,  and  to  neutralize  their  toxins  by 
mechanical  cleansing;  certainly  this  is  a  surgical  principle.  Unfortu- 
nately, any  attempt  to  carry  it  out  defeats  nature's  physiological  defense 
and  spreads  the  disease  beyond  the  limits  of  the  uterus. 

Among  the  curative  measures  which  have  been  suggested  and  used 
in  the  past,  a  few  may  be  mentioned  because  of  their  historical  interest, 
(i)  Intra-uterine  douches:  almost  every  chemical  antiseptic  or  proteid 
solvent  has  had  its  advocate,  the  list  will  include  bichlorid  and  biniodid 
of  mercury,  carbolic  acid,  formalin,  lysol,  creolin,  alcohol  and  iodin, 
saline,  and  Dakin's  solution. 

DeLee  has  summarized  the  objections  to  the  uterine  douche,  i.  It  is 
inefficient,  for  the  bacteria  are  beyond  its  reach  within  fifteen  minutes 
after  they  are  inoculated.  2,  It  is  painful,  sometimes  violent  uterine 
action  being  set  up.  3,  If,  as  sometimes  happens,  part  of  the  liquid  es- 
capes through  the  tubes  into  the  peritoneal  cavity  (Kosmak),  syncope, 
vomiting,  and  peritonitis  may  result.  4,  The  nervous  shock  sometimes 
causes  syncope,  even  convulsions  and  coma.  5,  The  antiseptic  em- 
ployed may  be  directly  poisonous.  Over  50  cases  of  bichloride  and  as 
many  more  of  carbolic  acid  poisoning  are  on  record,  the  chemical  being 
absorbed  by  the  uterus,  or  gaining  entrance  to  the  blood  through  the 
sinuses.  6,  Air  embolism  may  occur.  7,  Trauma  or  perforation  of  the 
uterus  is  a  possibility.  8,  Profuse  hemorrhage  may  result  from  the 
manipulation.  9,  Chill  and  fever,  the  infection  having  been  reinoculated 
by  the  douche.  10,  Sudden  death,  which  is  usually  from  air  emboUsm, 
but  may  be  due  to  cardiac  paralysis.  11,  Finally,  the  infection  may  be 
carried  up  higher  in  the  parturient  canal,  heretofore  unafifected. 

(2)  Swabbing  out  the  uterus,  with  gauze  wrapped  about  a  pair  of 
uterine  dressing  forceps,  was  a  method  of  cleansing  advocated  by  the 
opponents  of  the  curet.    The  gau?e  was  usually  wet  with  carbolic  acid, 


PUERPERAL  INFECTIONS  ill 

alcohol,  or  iodine.    Aside  from  producing  trauma  and  breaking  down  the 
granulation  zone,  little  clinical  value  can  he  claimed  for  it. 

(3)  Curage  or  digital  removal  of  the  uterine  content  was  very 
generally  endorsed,  and  some  authorities,  as  Williams,  Hirst,  and  E.  P. 
Davis,  advocate  aseptic  douches  before  and  after  the  operation,  Davis 
still  packs  the  uterus  with  washed  iodoform  gauze. 

Our  experience  has  been  that  all  such  manipulation  disturbs  the 
granulation  wall  and  is  followed  by  constitutional  reaction,  which  takes 
a  day  or  two  to  subside. 

Only  in  the  presence  of  dead  material  or  a  dead  fetus,  where  the 
bacillus  aerogenes  capsulatus  has  been  demonstrated,  should  any  active 
intervention  be  advised. 

(4)  Curettage. — Through  the  teachings  of  the  gynecological  sur- 
geon the  curet  has  had  very  extensive  use,  though  it  is  never  indicated  in 
the  puerperal  uterus.  The  dangers  of  the  curet  in  the  puerperal  uterus 
are  those  of  curettage  intensified.  It  breaks  through  the  wall  of  leuko- 
cytes and  spreads  the  infection,  allowing  the  bacteria  free  access  to  the 
lymph  channels,  and  the  venous  radicles  in  the  uterine  wall.  Repeatedly 
we  have  demonstrated  to  our  classes  the  impossibility  of  remoznng  the 
uterine  content  with  the  curet,  by  taking  a  uterus  which  has  just  been  re- 
moved by  hysterectomy,  and  systematically  curetting  its  cavity,  then 
opening  the  uterus  and  showing  the  effect  of  the  curettage.  The  endo- 
metrium is  removed  in  streaks  and  more  is  retained  than  has  been  re- 
Wtoved.  If  this  is  the  fact  in  a  firm  uterus  and  when  great  pains  are 
taken  to  be  thorough,  and  it  cannot  be  controverted,  how  much  more 
ineffectual  must  it  be  in  the  soft  puerperal  uterus.  Furthermore,  the 
bacteria  have  passed  beyond  the  reach  of  the  curet  and  invaded  the  deeper 
tissues.  Perforation,  hemorrhage  and  air  embolism  are  actual  possibili- 
ties when  the  curet  is  used.  For  several  years  we  have  avoided  the  use 
of  this  dangerous  instrument.  DeLee  aptly  puts  it,  when  he  says  it  seems 
fust  as  rational  to  curet  the  nose  cmd  throat  in  cases  of  diphtheria,  as  to 
curet  the  uterus  in  sepsis. 

Numerous  placental  forceps  have  been  devised  to  remove  the 
uterine  content  in  sepsis.  All  of  them  are  dangerous,  as  perforation  is 
no  infrequent  sequel  to  their  use.  Few  realize  how  easily  the  puerperal 
uterus  can  be  perforated. 

As  our  experience  in  sepsis  has  increased,  we  have  inclined  more  and 
more  toward  the  absolute  prohibition  of  every  member  of  our  staff  from 
entering  the  uterus  with  finger,  curet  or  forceps,  and  our  mortality  and 
morbidity  have  proportionately  decreased.  Even  the  packing  of  the 
uterus  with  iodine  soaked  gauze  has  been  abandoned.    In  a  few  cases  of 


112 


PELVIC  INFLAMMATION  IN  WOMEN 


putrid  endometritis,  with  poor  drainage  and  consequent  lochiometra,  we 
have  followed  the  suggestion  of  111  and  introduced  into  the  uterus,  to  the 
fundus,  a  soft,  small  sized  rubber  rectal  tube,  with  a  strip  of  packing 
gauze  carried  up  on  either  side  and  loosely  packed  into  the  cavity  and 
cervix.  When  these  are  in  place  50  per  cent  alcohol  is  poured  through 
the  tube  every  four  hours,  leaving  the  tube  and  gauze  in  situ.  Ill  claims 
that  the  presence  of  the  gauze  excites  contraction  and  retraction,  and  the 
alcohol  moistened  gauze  sterilizes  the  cavity  by  actually  destroying 
the  bacteria. 


Fig.  34. — Ill's  Method  of  Tre.\tixg  Putrid  Endometritis  with  Alcohol  Irrigations. 

After  the  bacteria  have  passed  out  of  the  uterus  into  or  through  the 
myometrium,  and  have  entered  the  lymphatics  or  blood  vessels,  it  is  evi- 
dent that  no  form  of  local  treatment,  within  the  cavity  of  the  uterus,  can 
have  the  slightest  effect  on  these  infective  bacteria,  except  to  push  them 
further  along  and  disseminate  their  toxins  into  the  general  circulation. 
We  have  already  shown,  in  the  pathology,  that  lymphatic  extension  either 
ends  in  a  parametric  exudate,  which  is  definitely  conservative  and  prO' 
tective,  or  in  a  pelvic  peritonitis,  which,  if  confined  to  the  pelvis  by  proper 
treatment,  is  just  as  conservative  a  process  as  the  tissue  reaction  in  the 
parametrium ;  or  the  bacteria  may  pass  into  the  blood  and  produce  a  bac- 
teriemia,  which  is  beyond  the  reach  of  local  treatment. 


PUERPERAL  INFECTIONS 


"3 


In  parametric  Invasions  our  plan  of  management  has  been  entirely 
expectant  in  the  belief  that  the  reaction  in  the  cellular  tissues  is  funda- 
mentally protective,  an  attempt  to  confine  the  bacteria  within  a  mass  of 
exudate;  hence,  this  is  favored  by  body  and  tissue  rest.  The  patient  is 
placed  in  the  Fozuler  posture  and  pelvic  structures  are  not  handled ;  the 
pain  is  relieved  with  opium,  in  the  form  of  morphin  or  codein  hypoder- 
matically  or  by  rectum,  and  the  application  of  an  ice  hag  over  the  affected 
part.  Catharsis  is  avoided,  and  the  lower  bowel  kept  empty  with  small 
low  enemata.  Blood  counts  are  made  daily,  for  the  leukocyte  count  shows 
the  degree  of  tissue  re- 
sistance. A  high  white 
cell  count  usually  pre- 
cedes the  drop  in  tem- 
perature. Only  about 
six  or  seven  per  cent  of 
these  parametrial  exu- 
dates suppurate ;  the 
vast  majority  ultimately 
end  in  resolution.  Cul- 
len  claims  that  this  ab- 
sorption can  be  hastened 
by  incision  just  above 
Poupart's  ligament,  and 
drainage  of  the  exudate 
between  the  folds  of 
the  broad  ligament ;  our 
experience  has  shown 
us  that  incision  and 
drainage  of  a  solid  exu- 
date only  prolong  the  reparative  process.  On  the  other  hand  the  em- 
ployment of  heat  for  long  periods  by  the  use  of  the  Gellhorn  or  Bier 
electric  baker  or  the  electric  thermopad  distinctly  favors  the  absorption 
of  an  exudate  by  the  production  of  a  circulator  stasis.  After  baring 
the  abdomen  and  covering  It  with  a  bath  towel,  the  baker  Is  applied 
for  one  or  two  hours  at  a  time,  maintaining  a  heat  of  140°  F.,  or  the 
thermopad  may  be  held  In  place  with  a  many  tailed  binder.  Only  when 
an  abscess  forms,  as  Is  shown  by  the  evening  elevations  In  temperature, 
by  the  Increase  In  the  polymorphonuclear  count,  and  by  fluctuation,  is 
incision  and  drainage  employed. 

Before  taking  up  the  management  of  peritonitis,  thrombophlebitis, 
and  bacterlemla,  a  few  words  on  the  general  supportive  treatment  of 


Fig.  35. — Site  of  Incision  Just  Above  Poupart's  Liga- 
ment WITH  A  "Cigarette"  Drain  Between  the 
Folds  of  the  Broad  Ligament. 


114  PELVIC  INFLAMMATION  IN  WOMEN 

the  individual  patient  may  not  be  amiss.  Broadly  speaking,  ezferything 
that  can  he  done  to  imp-roz'c  the  ivoman's  general  health  mill  be  an  aid  in 
combating  the  disease.  Fresh  air,  sunlight,  an  ample  amount  of  easily 
digested  food,  and  supportive  stimulation,  all  contribute  to  the  increase  of 
her  resisting  powers.  It  is  our  habit  to  have  our  septic  cases  cared  for  on 
the  roof,  where  they  may  remain  day  and  night;  the  fresh  air  increases 
their  appetite  and  favors  sleep,  while  the  sunlight  increases  the  red  cells 
and  hemoglobin. 

The  fever  seems  to  make  less  ravages  in  a  patient  who  is  treated  in 
the  open,  than  in  one  who  has  the  same  care  in  a  ward.    These  patients 


Fig.  36. — Harris  Drip.    Patient  on  Gatch  Frame.    Glucose-Soda  Solution  at  Same 
Level  in  Both  Can  and  Rectum. 


sleep  better,  and  sleep  is  a  prime  necessity  in  maintaining  the  nervous 
resistance.  Sleeplessness,  like  pain,  is  depressing  and  fatiguing  and  sleep 
must  be  secured  at  all  costs.  We  believe  that  a  moderate  amount  of 
opium,  either  hypodermatically  or  by  the  rectum,  to  relieve  pain,  is  less 
harmful  than  allowing  the  patient  to  suffer. 

Little  or  nothing  is  dotie  for  the  pyrexia,  unless  the  temperature  re- 
mains continuously  high,  when  the  fever  is  reduced  by  sponging  or  plac- 
ing an  ice  cap  on  the  head  or  over  the  heart,  or  an  ice  coil  over  the 
abdomen.  While  this  does  not  actually  reduce  the  temperature,  it  makes 
the  patient  feel  more  comfortable. 

All  catharsis  is  avoided  in  pelvic  infections.  In  the  acute  stage,  when 
it  is  necessary  to  empty  the  intestinal  tract,  the  lower  bowel  is  emptied 
daily  by  low  enemata  of  small  quantity;  this  causes  less  peristalsis  than 
cathartics  and  is  more  agreeable  to  the  patient.  Diarrhea  is  one  of  na- 
ture's methods  of  carrying  off  the  poison,  thus  ridding  the  system  of 
toxins;  however,  repeated  evacuations  are  exhausting  and  when  con- 


PUERPERAL  INFECTIONS 


"5 


tinued,  should  be  checked  by  saline  irrigation,  starch  and  opium  enemata, 
and  proper  regulation  of  diet. 

When  the  infection  spreads  to  the  peritoneum  and  there  are  symptoms 
of  peritoneal  involvement,  such  as  tympany  and  vomiting,  all  food  should 
he  withheld  from  the  stomach,  and  if  the  vomiting  persists,  the  stomach 
should  be  lavaged.  Nourishment  may  be  supplied  by  enteroclysis,  using 
a  five  per  cent  solution  of  glucose  in  a  weak  bicarbonate  of  soda  solu- 


FiG.  27- — Diagrammatic  Sagittal  Section  Showing  Isolation  of  Pelvis  in  Pelvic 
Inflammation.     Patient  in  Fowler  Position. 


tion.    If  this  is  used  by  the  Harris  drip,  a  very  considerable  quantity  of 
the  solution  will  be  taken  up  by  the  colon. 

In  perimetritis  and  pelvic  peritonitis,  we  attempt  to  obtain  localization 
by  the  elevated  trunk  posture  of  Fowler,  the  arrest  of  peristalsis  with 
morphin,  and  the  avoidance  of  cathartics.  Morphin  and  an  ice  coil 
will  generally  control  the  pain  unless  the  disease  is  progressive.  The 
secretory  functions  are  kept  active  by  the  continuous  use  of  the  Harris 
drip  and  daily  hypodermoclysis  of  saline.  If  the  peritonitis  shows  evi- 
dence of  extension,  as  appears  from  the  temperature  remaining  high, 
the  pulse  rate  being  accelerated,  the  leukocyte  count  being  30,000  or 
more,  with  a  polymorphonuclear  count  of  90  per  cent  or  more,  we  feel 
that  a  wide  cid  de  sac  incision  and  isolation  of  the  pelvis  with  gauze,  as 
suggested  and  practiced  by  the  late  Dr.  Pryor,  in  conjunction  with  the 
Fowler  elevated  trunk  posture,  and  the  continuance  of  intestinal  quiet 


Ii6 


PELVIC  INFLAMMATION  IN  WOMEN 


with  morphin  and  ice,  will  frequently  confine  the  infection  to  the  pelvic 
peritoneum  and  prevent  its  extension  to  the  general  peritoneal  cavity. 

While  the  clinical  picture  of  spreading  peritonitis  has  been  referred 
to  before,  little  positive  information  can  be  obtained  by  vaginal  examina- 
tion. 

Usually  the  abdomen  is  distended  and  the  tenderness  increased  over 
a  greater  area,  and  the  patient  complains  of  increasing  intestinal  pain. 


ef 


Fig.  38. — Placing  the  Gauze  Roll  Drains.    The  Posterior  Vaginal  Incision  Held 
Open  with  Long  Bladed  Retractors. 


Vaginal  examination  seldom  reveals  more  than  local  tenderness  and 
exquisite  sensitiveness  on  motion  of  the  cervix;  we  have  seldom  found 
bulging  of  the  cul  de  sac,  notwithstanding  this,  on  opening  the  ciil  de  sac, 
we  have  invariably  liberated  a  considerable  quantity  of  seropurulent 
material,  containing  cocci.  By  widely  opening  the  cid  de  sac  and  allow- 
ing this  exudate  to  escape,  and  then  isolating  the  pelvis  by  placing 
twisted  gauze  drains  from  pelvic  wall  to  pelvic  wall,  we  not  only  take 
care  of  the  exudate  already  formed,  but  relieve  the  patient  from  the 
absorption  of  toxins.  By  the  presence  of  the  gauze  we  excite  a  local 
peritoneal  reaction,  which  walls  off  the  pelvis  from  the  general  abdominal 


Fig.    39, — Counter    Incision    and    Drainage    Through 
THE  Loins  in  Purulent  Peritonitis. 


Fig.  40. — Suprapubic  "Stab  Drain"  in  Spreading  Peritonitis, 

117 


ii8 


PELVIC  INFLAMMATION  IN  WOMEN 


cavity,  as  the  litems  is  pushed  forward  and  becomes  adherent  to  the 
bladder  and  the  loop  of  the  sigmoid  falls  down  and  adheres  to  the  fundus 
of  the  uterus  and  bladder.  In  this  way  the  peritoneal  reaction  is  con- 
fined to  the  visceral  and  parietal  peritoneum  within  the  pelvis.  It  must  be 
understood  that  this  radical  method  is  not  employed  as  routine,  for  the 


Fig.  41. — Drawing  from  Autopsy  and  Operating  Table  Pathology,  Showing  Isola- 
tion OF  Pelvis  in  Cases  of  Postabortive  Peritonitis,  Favored  by  the  Fowler 
Elevated  Trunk  Posture. 

majority  of  the  cases  of  pelvic  peritonitis  and  perimetritis  tend  to  remain 
localized  within  the  pelvis,  and  the  exudate  is  absorbed. 

If  general  peritonitis  develops  in  the  puerperium,  there  is  no  treat- 
ment which  has  given  us  much  in  a  curative  way.  We  regard  the  symp- 
tom complex  of  increased  pulse  rate,  increased  distention,  abdominal 
pains  and  a  polymorphonuclear  count  of  90  per  cent  or  more  as  an 
indication  for  drainage.  Early  stab  wound  incision  and  drainage  by  the 
suprapubic  route,  with  counter  incisions  and  drains  in  the  loins  supple- 


PUERPERAL  INFECTIONS  119 

merited  with  posture,  lavage,  proctoclysis,  and  the  arrest  of  peristalsis 
with  morphin,  have  given  practically  no  better  result  than  the  expectant 
plan.  Altogether  fifteen  cases  have  been  studied;  seven  were  operated 
on ;  there  were  five  deaths.  Eight  were  treated  by  posture,  lavage,  proc- 
toclysis, hypodermoclysis,  morphin,  and  so  forth,  with  six  deaths.  Many 
patients  fail  to  localize  the  infective  process  in  the  pelvis,  owing  to  the 
energetic  measures  employed  by  the  attendant.  We  have  learned  by 
hitter  experience  that  puerperal  and  postabortal  infective  processes  are 
actually  extended  by  manual  and  instrumental  manipulation. 

In  bacteriemia,  we  have  the  presence  of  bacteria  in  the  blood;  these 
bacteria,  with  their  toxins,  produce  a  rapid  dissolution  in  the  cellular 
elements  of  the  blood  tissue,  destroying  the  red  cells  as  well  as  the 
leukocytes,  and  as  they  pass  along  the  blood  stream,  through  the  heart, 
the  kidneys,  and  the  liver,  produce  degenerative  changes  in  the  heart 
muscle,  cloudy  swelling  in  the  kidneys,  and  fatty  degeneration  in  the 
liver;  hence,  it  will  be  seen  that,  in  order  to  combat  bacteriemia,  nature 
must  offer  a  resistance  so  great  as  not  to  be  overcome  by  the  bacteria 
and  their  toxins. 

Necessarily,  the  whole  treatment  hinges  on  our  ability  to  increase 
the  individual's  resistance  sufficiently  to  make  the  fight.  Fresh  air, 
sunlight,  food,  repeated  small  blood  transfusions,  and  supportive  stimu- 
lation, sum  up  the  therapy. 

Clinically,  we  must  regard  the  blood  as  a  tissue  with  all  the  char- 
acteristics of  other  tissues,  hence  it  is  obvious  that  the  introduction  of 
bacteria  and  their  toxins  into  the  blood  stream  must  result  either  in  a 
cell  reaction  or  in  a  cell  destruction.  Bacteriologists  have  shown  that 
blood  serum  makes  a  good  culture  medium  for  the  culture  of  bacteria. 
If  this  is  so  in  the  laboratory,  it  is  also  true  in  the  blood  stream;  hence 
there  is  no  way  by  which  nature  can  overcome  the  rapid  propagation  of 
bacteria,  except  by  increasing  the  leukocytic  resistance.  The  leukocyte 
is  a  bacterial  enemy,  and  whether  the  patient  recovers  or  dies  depends 
upon  whether  the  bacteria  are  killed  bv  the  leukocytes  or  the  leukocytes 
destroyed  by  the  bacteria. 

Various  attempts  have  been  made  by  the  profession  to  check  bac- 
terial growth,  and  to  destroy  the  bacteria  already  in  the  blood  by  the 
introduction  into  the  blood  stream  of  antibactericides — various  anti- 
septics, foreign  material — by  blood  dilution  and,  finally,  by  the  introduc- 
tion of  vegetable  matter.  Recently  Potel  has  suggested  injections  of  a 
10  per  cent  solution  of  peptone  in  distilled  water,  using  10  c.cm.  of 
the  solution  daily  by  intramuscular  and  intravenous  injection.  The 
latter,  however,  produces  considerable  reaction. 


120  PELVIC  INFLAMMATION  IN  WOMEN 

Chalfont  and  Miller  report  a  series  of  streptococcic  infections, 
which  have  yielded  to  the  introduction  of  salvarsan  into  the  blood.  My 
own  experience  with  salvarsan  used  exactly  as  recommended  by  Chal- 
font and  Miller,  in  their  paper,  has  not  produced  the  results  claimed  by 
these  writers;  and  the  more  one  thinks  of  the  actual  pathological  proc- 
esses which  take  place  in  the  blood  stream  after  the  introduction  of 
hemolytic  bacteria,  the  more  one  must  wonder  how  the  introduction  of 
salvarsan  can  in  any  way  affect  the  life  and  growth  of  these  bacteria. 

On  the  other  hand,  we  all  know  that  infection  is  arrested  by  the  de- 
velopment of  a  leukocytosis.  We  know  that  the  leukocyte  is  a  bac- 
terial enemy ;  we  know  that  it  is  a  struggle  to  determine  the  fittest,  and 
whether  the  bacteria  are  killed  by  the  leukocyte,  or  the  leukocyte  by  the 
bacteria  depends  on  the  supply  of  each.  It  has,  therefore,  appealed  to  us 
that,  notwithstanding  the  poor  results  (reported  by  Linderman  and 
others),  in  the  treatment  of  postoperative  septicemias  due  to  general 
surgical  causes,  that  the  use  of  small  repeated  blood  transfusions  offers 
the  only  plausible  treatment  in  these  blood  infections. 

Transfusion  in  infection  would  seem  to  serve  the  double  purpose  of 
lessening  the  secondary  anemia  and  supplying  normal  active  leukocytes 
for  temporary  defense,  besides  raising  the  blood  pressure,  which  helps 
to  restore  functional  activity  of  the  organs  bearing  the  brunt  of  the 
defense. 

In  a  study  of  the  poor  results  occurring  among  the  surgical  sep- 
ticemias, we  have  become  convinced  that  it  is  because  the  blood  re- 
sistance is  not  increased  at  a  sufficiently  early  date,  that  transfusion,  in- 
stead of  being  used  in  a  rational  ivay,  has  been  used  as  a  last  resort. 

Many  operators  have  been  deluded  into  the  belief  that,  when  a  large 
quantity  of  blood  is  poured  into  the  blood  stream,  they  get  the  effect 
from  the  quantity  injected.  Large  transfusion  not  only  often  em- 
barrasses the  pulmonary  circulation,  but  engorges  the  liver  and  spleen 
and  thus  interferes  with  their  functional  activity.  We  must  appreciate 
that  the  effect  of  transfusion  is  but  temporary,  that  the  blood  cells 
thrown  in  are  rapidly  destroyed,  and  that  the  real  effect  is  but  a  stimula- 
tion of  the  tissues  to  increased  cellular  proliferation. 

We  have  found  that,  within  four  or  five  days  after  a  transfusion, 
the  hemoglobin  shows  a  marked  reduction  from  the  percentage  ob- 
tained immediately  after  the  operation,  and  that,  while  the  leukocytes 
are  immediately  increased,  they  rapidly  fall. 

On  this  basis,  accepting  these  clinical  facts  as  truths,  for  they  have 
been  certified  to  by  repeated  obsen-ations,  we  have  during  the  past  year 
been  studying  the  effects  of  repeated  small  transfusions  of  citrated  blood 


PUERPERAL  INFECTIONS  121 

in  bacterial  invasions  of  the  blood  stream.  So  far,  we  have  treated 
four  cases  of  thrombophlebitis,  with  one  death,  and  six  cases  of  bac- 
teriemia,  with  one  death.  The  two  fatal  cases  were,  in  our  opinion, 
too  far  advanced,  as  the  number  of  colonies  of  bacteria  to  the  cubic 
centimeters  were  so  numerous  that  it  is  doubtful  if  anything  could 
have  changed  the  outcome.  In  the  fatal  instance  which  occurred  in 
thrombophlebitis,  the  hypogastric  and  ovarian  vein  had  been  tied  before 
transfusions  were  given.  This  case,  as  have  all  of  the  others,  showed 
a  marked  temporary  improvement  following  the  transfusion. 

Small  transfusions  of  citrated  blood  are  given  every  third  day, 
care  being  taken  not  to  use  the  same  donor  for  more  than  two  trans- 
fusions. Quantities  of  300-360  c.cm.  are  used,  and  given  very  slowly. 
The  transfusion  is  preceded  by  a  hypodermic  of  a  third  of  a  grain  of 
morphin;  we  have  found  that  this  materially  diminishes  the  severity  of 
the  reaction.  The  blood  injections  are  best  given  in  the  morning,  when 
the  temperature  is  down.  Our  experience  is  limited,  but,  so  far,  has 
been  such  as  to  encourage  us  in  the  continuance  of  the  method.  De- 
tailed blood  studies  have  been  made  before  and  after  each  transfusion; 
the  leukocyte  count  has  been  invariably  increased  and  the  blood  pres- 
sure has  been  raised.  Temporarily  the  red  cells  and  hemoglobin  have 
been  increased;  these,  however,  have  shown  rapid  destruction  in  the 
succeeding  forty-eight  hours.  The  pulse,  in  the  favorable  cases,  has  al- 
zvays  improved  in  quality  and  rate,  whether  the  temperature  has  shown 
any  favorable  change  or  not. 

The  advantages  of  citrated  blood  are  obvious;  its  simplicity,  the  fact 
that  the  patient  may  remain  in  bed,  the  absence  of  the  donor,  and 
naturally  the  lack  of  psychic  disturbances. 

Gas  Bacillus  Infection. — Symptomatology. — A  brief  word  will 
sufifice.  We  have  all  grades  of  infection  from  the  mild  toxemia,  with 
only  a  slight  rise  of  pulse  and  temperature,  in  the  puerperium,  to  the 
rapidly  fatal  cases  of  gas  sepsis.  In  the  puerperal  cases  the  symptoma- 
tology depends  upon  whether  the  uterine  wall  and  the  blood  are  invaded. 
If  these  gas  builders  once  get  beyond  the  confines  of  the  genital  tract 
and  become  mixed  with  streptococci,  they  usually  evince  severe  invasive 
qualities.  Leukocytosis  is  scant  and  the  toxemia  is  rapid  and  prostrating. 
Vomiting  and  collapse  are  prominent  symptoms,  including  hemolysis, 
jaundice,  and  bleeding  into  the  vital  organs  and  on  the  serous  surfaces 
and  skin.  There  are  present  rapid  pulse  and  respiration  and,  toward 
the  end,  an  ashy  gray  color  to  the  skin,  a  progressive  coldness  of  the 
body,  beginning  in  the  hands  and  feet,  with  often  a  clear  intellect  to 
the  end.    General  body  emphysema  may  be  present. 


122  PELVIC  INFLAMMATION  IN  WOMEN 

Diagnosis. — This  must  be  made  bacteriologically.  Any  temperature 
in  the  puerperium,  which  seems  to  emanate  from  infection  of  the  genital 
tract,  should  be  checked  up  by  intra-uterine  cultures,  grown  both  aero- 
bically  and  anaerobically.  It  is  important  to  make  an  early  bacteriologic 
diagnosis,  in  order  to  start  combative  measures.  The  gas  bacillus  alone 
is  harmless  and  ever  present,  but  when  combined  with  the  streptococcus 
is  rapidly  virulent. 

Prognosis  depends  upon  the  virulence  of  the  infecting  strain,  its 
symbiosis  with  other  organisms,  the  resistance  of  the  patient,  the  amount 
of  dead  material  in  the  uterus,  the  amount  of  trauma  at  labor.  The  fatal 
issue  depends  upon  the  invasion  of  the  uterine  wall. 

Wright  shows  that  measuring  the  antitryptic  power  and  alkalinity  of 
the  blood  aids  in  prognosis. 

Treatment. — The  treatment  is  local  and  general.  Locally,  what  are 
we  to  do?  Numerous  authors  have  advised  keeping  the  uterus  open 
to  the  outside  air  by  means  of  packing,  drainage  tubes,  etc.  Marvel  saw 
five  cases,  all  fatal  except  the  last,  in  which  he  used  intra-uterine  irriga- 
tion, with  peroxid  of  hydrogen. 

Shall  we  remove  the  infected  content  of  the  uterus?  In  the  abortion 
cases  with  bacillus  aerogenes  capsulatus  in  the  discharge,  good  results 
are  reported.  If  the  dead  material  is  the  baby,  as  in  my  case,  I  would 
say,  by  all  means,  remove  it.  Large  amounts  of  infected  placental  tissue 
should  best  be  gently  removed,  though  this  may  be  dangerous  in  the 
presence  of  other  infecting  organisms,  such  as  streptococcus,  staphy- 
lococcus, etc.  We  have  seen,  however,  that  the  germs  grow  in  the  dead 
tissue  and  increase  their  virulence,  and  large  amounts  of  placenta  tissue 
should  be  removed.  Sir  A.  E.  Wright  suggests  the  early  intravenous 
use  of  alkalis,  and  this  would  seem  to  be  logical,  though  the  measure 
has  lost  something  in  importance  since  we  know  that  there  is  a  true 
toxemia  as  well  as  an  acidemia. 

Our  best  hope  for  therapy  lies  in  the  use  of  the  antitoxin  serum 
elaborated  by  Bull.  This  serum  should  be  given  immediately  upon 
finding  the  bacillus  aerogenes  capsulatus  in  the  lochia.  And  our  results 
will  depend  upon  an  early  recognition  of  the  condition.  I  cannot  impress 
upon  you  too  strongly  the  importance  of  the  early  bacteriological  diag- 
nosis, and  the  necessity  in  all  cases  for  the  immediate  use  of  the  serum. 


CHAPTER  VI 

FIBROSIS  UTERI,  METRITIS,  SUBINVOLUTION 

Invasion  of  endometrium  by  infective  bacteria — Gross  pathology  of  chronic  metritis, 
subinvolution,  and  uterine  hypertrophy — Conditions  which  hinder  normal  involu- 
tion— Some  change  in  menstruation  characteristic  of  metritis  or  subinvolution — 
Thrombokinase — Hemorrhage  the  most  common  symptom — Treatment  by  rest, 
hot  douches,  vaginal  tamponade,  galvanism,  drugs,  radium — Surgical  treatment — 
Curettage — Hysterectomy. 

Fibrosis  uteri  is  a  term  which  is  appHed  to  a  pathological  lesion 
directly  attributable  to  infection  of  the  uterus.  It  commonly  occurs  sub- 
sequent to  repeated  parturition  or  abortion,  and  therefore  it  is  closely 
allied  with  chronic  fuetritis  and  should  be  considered  with  it. 

When  the  uterus  is  acutely  infected,  the  endometrium  becomes  in- 
vaded by  infective  bacteria,  such  as  the  staphylococcus,  streptococcus, 
colon,  or  mixed  organisms,  and  there  is  a  defensive  inflammatory  reac- 
tion on  the  part  of  the  uterine  tissues.  The  endometrium  is  a  lymphoid 
structure  without  a  submucosa,  hence  the  prolongation  of  its  tubular 
glands  extends  into  the  underlying  muscular  coat.  Therefore,  in  the 
course  of  time,  reaction  to  this  invasion  in  the  form  of  serum,  round  cells, 
plasma  cells,  and  leukocytes  is  poured  out  into  the  stroma  and  the  sub- 
jacent muscle  structures. 

The  longer  the  infection  is  continued  the  greater  is  the  number  of 
round  tissue  cells  which  are  deposited.  This  deposition  of  round  tissue 
cells  thickens  the  wall  of  the  uterus  and  increases  its  gross  bulk ;  and,  by 
pressure,  it  destroys  the  muscle  fibers,  which  are  replaced  by  fibrous 
tissue.  Therefore,  when  the  process  comes  to  the  chronic  state,  we  find, 
histologically,  that  the  walls  of  the  uterus  are  composed  of  an  increase 
of  yellow  elastic,  and  fibrous  tissue,  as  well  as  an  increase  in  the  gross 
bulk. 

A  further  study  of  the  pathological  changes  shows  us  that  the  endo- 
metrium is  almost  always  in  a  state  of  glandular  hypertrophy.  The 
glands  are  larger,  and  dilated,  and  actually  approach  an  early  adenoma- 
tous growth.  The  arteries  become  thick  walled  and  are  surrounded  by 
a  large  amount  of  elastic  tissue,  which  inhibits  the  normal  muscular  con- 
tractions from  controlling  the  blood  vessels;  consequently,  bleeding  is 
the  most  constant  symptom. 

123 


124  PELVIC  INFLAMMATION  IN  WOMEN 

Geist  says  that  the  same  pathology  may  exist  in  women  who  have 
had  repeated  pregnancies,  yet  who  have  no  definite  history  of  infection; 
and  claims  that  long  continued  subinvolution  will  explain  the  similarity. 
Our  clinical  experience  is  that  subinvolution  is  akvays  a  result  of  a  mild 
degree  of  infection,  and  therefore  we  must  have  some  changes  due  to  a 
long  continued,  low  type  inflammation;  hence,  the  clinical  substantiates 
the  pathological  findings. 

The  Gross  Pathology  of  Chronic  Metritis,  Subinvolution, 
AND  Uterine  Hypertrophy. — The  gross  specimen  in  these  conditions, 
when  examined  macroscopically,  shows  the  uterus  to  be  symmetrically 
enlarged;  its  w^alls  have  a  thickness  of  from  three  fourths  to  one  and 
one  fourth  inches;  the  cavity  has  a  depth  of  from  four  to  five  inches,, 
and  the  whole  organ  is  denser  and  harder  than  normal.  On  bisection, 
the  wall  looks  "streaky"  in  the  outer  third.  The  "streakiness"  is  due  to 
the  muscle  bundles  being  separated  by  large  quantities  of  elastic  and 
fibrous  tissue.  The  vessels  are  enlarged  and  stand  out  on  the  cut  sur- 
face; the  endometrium  is  either  very  thin  or  excessively  thick. 

Dividing  these  uteri  into  the  three  types  mentioned  above,  which  we 
group  clinically  under  the  head  of  chronic  metritis,  Shaw  has  found 
in  a  microscopical  study  of  lOO  specimens,  that  95  fell  into  the  class  of 
subinvolution,  four  were  due  to  hypertrophy,  and  only  one  was  the  result 
of  a  true  chronic  inflammation. 

To  prove  microscopically  what  occurs  in  chronic  metritis,  it  is  neces- 
sary to  make  use  of  a  uterus  which  has  never  been  pregnant,  but  in  which 
there  has  been  an  acute  or  chronic  inflammation,  both  uterine  and  peri- 
uterine. 

In  such  a  uterus,  when  the  acute  inflammation  resolves,  the  inflam- 
matory exudate  is  transformed  into  fibrous  tissue,  and  the  muscle  tissue 
is  also  more  or  less  transformed.  So,  in  the  uterus  which  has  been  the 
site  of  this  inflammatory  process,  we  should  find  a  great  increase  in  the 
amount  of  fibrous  tissue,  with  an  increase  in  the  thickness  and  density 
of  the  uterine  walls.  The  muscle  bundles  are  diminished  in  size  and 
separated  by  masses  of  fibrous  tissue.  In  the  earlier  stages  the  tissues 
will  be  invaded  with  leukocytes  and  plasma  cells.  Later,  these  will  have 
completely  disappeared. 

The  effect  of  sepsis  in.  the  puerperium  is  apparently  to  delay  involu- 
tion, and  it  does  not  in  itself  produce  any  microscopic  changes  in  the 
uterine  wall,  except  those  due  to  the  persistence  of  a  prolonged  hyper- 
emia. 

For  a  clearer  understanding  of  these  processes,  it  wall  not  be  amiss 
to  briefly  review  the  normal  process  of  involution. 


FIBROSIS  UTERI,  METRITIS,  SUBINVOLUTION 


I2S 


Helme  claims  that  there  is  no'  fatty  degeneration  in  the  muscle  fibers, 
but  simply  a  diniimition  in  the  volume  of  both  the  muscle  fibers  and  the 
connective  tissue.  This  change  is  brought  about  by  a  process  which  is 
probably  chemical,  a  sort  of  peptonization  of  the  tissues,  which  makes 
the  contents  of  the  muscle  cells  more  soluble,  so  that  they  can  pass  with 
greater  readiness  into  the 
lymph  stream.  This  atro- 
phy goes  on  simultane- 
ously and  equally  in  all 
parts  of  the  organ.  No 
group  of  degenerated 
cells  is  found  among  the 
healthy  tissues.  On  the 
other  hand,  Goodall  has 
found  definite  evidence  of 
fatty  degeneration  in  the 
muscle  fibers. 

A  review  of  Goodall's 
work  deserves  our  consid- 
eration. He  says  "Dur- 
ing pregnancy  there  is  a 
great  increase  of  all  the 
constituent  elements  of 
the  uterus.  The  muscle 
fibers  become  enormously 
enlarged,  while  the  fibrous 
and  elastic  tissue  is  also 
increased  in  amount;  but 
all  through  pregnancy 
these  three  elements  re- 
tain the  same  proportion 
and  distribution  as  in  the 
virgin  uterus.  Coinci- 
dentally  a  great  change  takes  place  in  the  blood  vessels  of  the  organ. 
They  enlarge  sufficiently  to  supply  the  growing  organ  and  convey  the 
large  amount  of  blood  necessary  for  the  sustenance  of  the  fetus.  All 
of  the  vessels  enlarge,  but  especially  those  of  the  subplacental  site,  which 
become  large  sinuses. 

"After  labor  the  uterus  undergoes  a  sudden  tissue  change.  Soon 
after  delivery,  the  fundus  is  at  the  umbilicus  and  the  uterus  weighs  from 
one  and  one  half  to  two  and  one  half  pounds,  while  in  three  weeks  after 


Fig.  42. — Drawing  from  Specimen  in  Author's 
Collection  Showing  Increase  in  Constitu- 
ent Elements,  the  Thickened  Decidua  of 
Pregnancy  and  Early  Placenta  Formation. 


126  PELVIC  INFLAMMATION  IN  WOMEN 

delivery  the  uterus  weighs  only  from  four  to  five  ounces.  This  rapid 
change  in  size,  weight  and  involution  is  completed  in  from  eight  to 
twelve  weeks. 

"Soon  after  delivery  fatty  degeneration  occurs  in  the  muscle  fibers. 
This  causes  a  great  reduction  in  their  size,  while  many  are  completely 
destroyed.  Likewise,  immediately  after  delivery  there  is  a  great  reduc- 
tion in  the  amount  of  blood  conveyed  by  the  uterine  vessels,  which 
reduction  continues  as  the  involution  progresses. 

"To  meet  this,  definite  changes  occur  in  the  vessel  walls  to  reduce 
their  lumina  to  their  normal  carrying  capacity.  The  vessels  in  the  sub- 
mucosal layer  become  blocked  imth  thrombi.  In  others,  especially  in  the 
deeper  layer  of  the  uterus,  a  ring  of  thrombus  is  formed  zvithin  the  ves- 
sel which  leaves  its  lumen  still  patent,  but  diminished  in  size.  Coincident 
with  this  thrombosis,  the  fibrous  tissue  in  the  media  of  the  vessel  becomes 
markedly  swollen  and  hyaline,  and  the  elastica  interna  undergoes  'vitre- 
ous degeneration.'  Instead  of  forming  a  thick  black  ring  when  stained 
with  W'eigert-Van  Giesen  solution,  the  elastica  interna,  which  becomes 
enormously  thickened,  stains  brick  red  in  color  and  finally  yellow. 

"In  this  early  stage  we  find  some  of  the  vessels  filled  with  thrombi, 
others  lined  with  thrombus,  and  others  containing  no  thrombus  at  all. 
Most  of  the  elastica  interna  is  enormously  swollen  and  has  changed  in 
color  to  brick  red,  bright  red,  or  yellow.  The  media  contains  fibrous 
tissue,  swollen  in  appearance,  and  hyaline,  with  free  nuclei. 

"The  elastic  fibrils  in  the  media  undergo  Vitreous  degeneration,'  then 
become  swollen  and  change  their  staining  properties  in  just  the  same 
way  as  did  the  elastica  interna.  The  adventitia  undergoes  the  same 
hyaline  changes  as  the  fibrous  tissue  of  the  media. 

"The  next  step  is  for  the  hyaline  tissue  of  the  media  to  flow  through 
the  degenerated  elastica  interna  and,  where  a  thrombus  is  present,  to 
convert  it  completely  into  hyaline  tissue;  when  no  thrombus  is  present 
this  hyaline  material  flows  around  the  sides  of  the  vessel  adjacent  to  the 
elastica  interna,  leaving  only  the  small  lumen  necessary. 

"In  these  vessels,  which  are  filled  with  thrombus,  the  lumen  becomes 
completely  occluded  with  the  hyaline  material,  which  is  gradually  ab- 
sorbed, so  that  the  edges  of  the  elastica  interna  gradually  approximate 
and  completely  obliterate  the  vessel. 

"In  the  vessels  which  contained  only  a  layer  of  thrombus,  or  where 
the  hyaline  material  flowed  in  without  any  previous  clotting,  a  lumen 
is  preserved,  which  now  becomes  lined  by  a  layer  of  cells  with  large 
nuclei,  and  these  form  the  endothelial  lining  of  the  new  vessel.  Coinci- 
dentally  with  this  growth  the  hyaline  material  becomes  invaded  with 


FIBROSIS  UTERI,  METRITIS,  SUBINVOLUTION  127 

muscle  and  fibrous  cells,  which  gradually  convert  the  hyaline  material 
into  a  muscle  and  fibrous  ring,  the  media  and  adventitia  of  the  new 
vessel.  At  this  stage  we  find  the  new  vessel  surrounded  by  the  old 
vessel  wall,  the  old  elastica  interna  being  much  swollen  and  in  a  stage 
of  'vitreous  degeneration'  and  the  old  media  containing  swollen  hyaline, 
fibrous,  and  elastic  tissue. 

"Between  the  old  and  new  vessel  walls  is  the  interarterial  space  filled 
with  hyaline  material. 

"When  these  new  vessels  are  formed,  the  next  important  step  in 
involution  is  the  degeneration  and  absorption  of  the  old  vessel  walls. 

"Extensive  fatty  degeneration  occurs  in  the  old  vessel  walls  which,  if 
involution  is  complete,  entirely  destroys  the  muscle  fibers  of  the  old 
media,  while  at  the  same  time  the  degenerated  elastic  and  fibrous  tissue 
of  the  old  media  and  adventitia  is  absorbed.  The  old  vessel  is  absorbed 
and  the  new  vessel  is  left  without  any  trace  of  the  old  surrounding  it." 

Conditions  Which  Hinder  the  Process  of  Normal  Involution 
are: 

1.  Advancing  age, 

2.  Frequent  pregnancies, 

3.  General  chronic  and  acute  diseases, 

4.  Local  pelvic  disease, 

5.  Retained  pieces  of  placenta  and  membranes, 

6.  Septic  infection,  often  so  mild  that  the  patient  apparently  has 
a  normal  puerperium,  except  that  involution  is  retarded. 

When  any  of  these  conditions  has  operated  to  delay  or  stop  the  course 
of  normal  involution,  degeneration  of  the  muscular  tissue  of  the  uterine 
wall  is  arrested  and  the  organ  remains  larger  than  when  the  normal 
process  has  gone  on  without  interruption.  The  fibrous  and  elastic  tissue 
throughout  the  wall  has  degenerated  and  become  swollen,  preparatory  to 
being  absorbed,  but,  the  absorption  process  having  been  arrested,  these 
swollen,  fibrous  and  elastic  tissues  gradually  regain  their  normal  func- 
tions. Consequently,  elastic  and  fibrous  tissue  is  found  in  increased 
quantity  between  the  muscle  bundles,  especially  in  the  outer  third  of  the 
uterus,  and  there  is  also  a  large  amount  of  unabsorbed  muscular  tissue; 
these  all  contribute  to  increase  the  uterine  bulk.  New  vessels  have  been 
formed  and,  according  to  the  amount  of  diminution  required  for  each 
vessel,  several  new  arteries  or  one  complete  new  artery  will  be  found 
within  the  lumen  of  the  old  one. 

Early  in  the  puerperium  these  new  vessels  were  surrounded  by  the 
old  vessel  wall,  which  underwent  changes  preparatory  to  absorption,  the 


128  PELVIC  INFLAMMATION  IN  WOMEN 

elastica  interna  being  enormously  swollen,  the  fibrous  and  elastic  fibers  of 
the  media  swollen  and  hyaline.  With  the  arrest  of  involution  this  old 
wall  is  not  absorbed  and  the  elastic  and  fibrous  tissues  regain  their  prop- 
erty, and  so  the  neur  vessels,  or  groups  of  new  vessels,  will  nozu  be  found 
surrounded  by  thick  slabs  of  elastic  tissue  and  by  the  remains  of  the  old 
media,  thickly  impregnated  with  elastic  tissue. 

At  first  the  uterine  wall  is  soft,  but  later  the  tissues  become  more 
and  more  compact,  making  it  feel  firm  and  hard.  In  the  walls  of  the 
veins  much  more  elastic  tissue  will  be  found,  especially  in  cases  of  sub- 
involution due  to  wasting  diseases. 

In  some  cases  there  have  been  alternating  periods  of  involution  and 
arrested  involution.  In  these  the  uterine  arteries  will  be  found  with 
alternating  rings  of  muscular  and  elastic  tissue.  The  endometrium  is 
usually  much  thickened,  to  even  eight  or  nine  times  the  normal  thick- 
ness. The  glands  are  dilated  and  spiral  in  shape  and  may  be  increased 
in  number,  or  the  uterus  may  have  very  little  endometrium..  To  sum- 
marize the  changes  due  to  subinvolution : 

The  uterus  is  symmetrically  enlarged  and  hard;  on  cut  surface  the 
vessels,  with  their  surrounding  tissues,  are  strikingly  visible  and  stand 
out  from  the  surface;  the  endometrium  is  thickened  or  diminished ;  the 
microscope  shows  some  increase  in  the  amount  of  fibrous  and  elastic  tis- 
sue between  the  muscle  fibers,  with  a  large  accumulation  of  elastic  tissue 
around  the  arteries  and  groups  of  arteries. 

Some  change  in  menstruation  is  strikingly  characteristic  of  metritis 
or  subinvolution;  hence,  it  may  be  well  to  study  the  origin  of  the  hemor- 
rhage in  these  conditions.  This  bleeding  is  in  all  probability  due  to  the 
collection  of  fibrous  and  elastic  tissue  around  the  arteries,  which  pre- 
vents the  muscular  tissue  of  the  uterus  from  exercising  its  normal  con- 
trol over  these  vessels,  and  thus  from  regulating  the  amount  of  blood 
which  passes  through  them. 

It  has  already  been  mentioned  that  the  endometrium  may  be  hyper- 
trophic or  atrophic.  In  the  hypertrophic  variety,  the  hemorrhage  may 
be  due  to  the  changes  in  the  endometrium,  though  to  what  extent  they 
PRODUCE  OR  INCREASE  the  hemorrhage  in  these  cases  we  cannot  at  present 
l3e  certain. 

The  studies  of  Beckwith  and  Whitehouse  seem  to  throw  new  light 
on  this  subject.  When  blood  is  poured  out  into  a  tissue,  as  into  the 
endometrium  during  menstruation,  it  comes  into  contact  with  a  sub- 
stance called  "thrombokinase."  This  substance,  which  varies  in  amount 
in  different  tissues,  promotes  the  union  of  thrombogen  and  the  calcium 
salts  to  produce  thrombin ;  the  latter  then  exercises  a  quantitative  action 


FIBROSIS  UTERI,  METRITIS,  SUBINVOLUTION  129 

upon  the  fibrinogen,  converting  it  into  fibrin,  the  proteid  which  forms 
the  organic  base  of  all  clot. 

"Thrombokinase"  is  especially  plentiful  in  the  endometrium  and  is 
nature's  provision  for  checking  excessive  hemorrhage  in  an  organ  which 
is  subject  to  periodic  hemorrhages.  The  clot  formed  by  the  action  of 
this  "thrombokinase"  blocks  the  vessels  and  in  a  healthy  endometrium 
prevents  excessive  hemorrhages.  If  from  any  cause  the  "thrombokinase"' 
is  diminished  in  amount,  clotting  of  the  blood  will  be  delayed  and  there 
will  be  severe  hemorrhage. 

WhiteJionse  considers  this  to  be  the  cause  of  excessive  hemorrhage 
in  uteri  which  have  an  atrophic  endometrium,  as  this  atrophied  structure 
does  not  produce  the  necessary  amount  of  "thrombokinase." 

Besides  "thrombokinase,"  there  is  another  substance  produced  in 
the  endometrium,  "thrombolysin,"  which  has  a  marked  effect  on  the 
production  of  hemorrhage. 

Owing  to  the  "thrombokinase,"  clots  are  found  in  the  uterus,  but 
in  the  menstrual  blood  found  in  the  vagina  in  women  with  normal  men- 
struation there  are  no  clots ;  this  is  due  to  "thrombolysin,"  which  has  the 
power  of  dissolving  blood  clot,  and  in  the  normal  uterus  dissolves  the 
uterine  clot  formed  by  the  "thrombokinase"  before  it  reaches  the  vagina. 

In  a  normal  uterus  the  amounts  of  "thrombokinase"  and  "throm- 
bolysin"  are  balanced,  the  clotting  is  produced  in  the  uterus  by  the 
"thrombokinase"  and  excessive  hemorrhage  checked,  while  later  these 
same  clots  are  dissolved  by  the  "thrombolysin"  and  the  dark  fluid  blood 
passes  through  the  os  into  the  vagina. 

If  the  amount  of  "thrombolysin"  is  in  excess,  the  blood  clot  will  be 
too  rapidly  dissolved  and  the  blood  vessels  again  opened  up  with  a  result- 
ing hemorrhage. 

From  these  experiments  of  Whitehouse  it  would  seem  that  hemor- 
rhages in  metritis  may  be  due  either  to  a  diminution  in  the  amount  of 
"thrombokinase"  or  an  excessive  amount  of  "thrombolysin,"  the  supply 
of  the  ferments  depending  apparently  on  the  cellular  activity  of  the 
endometrium. 

In  subinvolution  the  hemorrhage  may  be  explained,  in  addition  to 
these  chemical  phenomena,  by  the  want  of  muscular  control  over  the 
vessels,  due  to  the  excess  of  elastic  tissue  about  them. 

Etiology. — Fibrosis  is  commonly  found  in  multiparae  between  the 
ages  of  thirty-five  and  forty-five,  almost  never  in  the  virgin,  unless  th€re 
has  been  a  history  of  previous  chronic  inflammation,  and  there  is  com- 
monly some  relaxation  of  the  pelvic  floor. 

Bennett  states  that  "to  this  class  belong  a  large  proportion  of  the  pop- 


130  PELVIC  INFLAMMATION  IN  WOMEN 

ulation  of  the  sofa  and  bath  chair  type,  nervous,  debihtated,  and  dyspeptic 
females,  who  wander  from  medical  man  to  medical  man  seeking  relief 
from  weakness." 

Although  this  condition  is  more  frequent  toward  the  latter  end  of 
sexual  activity,  it  is  at  times  found  in  early  life.  Watson  reports  a 
patient  of  twenty-three  who  required  hysterectomy. 

Symptoms  and  Signs. — There  are  three  cardinal  symptoms,  (i) 
hemorrhage,  (2)  leukorrhea,  and  (3)  pain;  most  patients  complain  of 
a  combination  of  these. 

The  uterus  is  symmetrically  enlarged  and  hard  and  is  usually  insen- 
sitive to  manipulation.  Section  will  show  that  there  are  no  fibromyoma- 
tous  nodules.  The  weight  tends  to  cause  the  uterus  to  antevert,  retro- 
vert,  or  prolapse.  In  about  25  per  cent  the  uteri  are  retroverted  and 
prolapsed.  Some  degree  of  chronic  endocervicitis  is  always  associated. 
This  involvement  of  the  cervix  tends,  through  its  lymphatic  drainage  by 
way  of  the  uterosacral,  to  produce  a  mild  uterosacral  cellulitis. 

The  heavy  uterus  drags  on  the  tender  uterosacrals,  and  backache, 
constant  and  tiring,  is  the  result. 

The  most  common  symptom  hozvever  is  hemorrhage.  The  hemor- 
rhage may  take  the  form  of  metrorrhagia,  in  which  case  the  patient  has 
a  more  or  less  constant,  bloody  discharge  from  the  uterus,  which  increases 
in  amount  at  the  time  of  the  regular  periods.  The  bleeding  may  appear 
as  a  menorrhagia,  the  flow  being  more  profuse  and  prolonged  at  each 
menstrual  date,  until  sometimes  the  intermenstrual  interval  is  reduced 
to  four  or  six  days. 

Secondary  anemia  follows;  this  produces  the  train  of  general  symp- 
toms complained  of  by  these  chronic  invalids,  for  a  poor  state  of  health 
explains  the  tiredness,  indigestion,  flatulence,  headache,  etc.,  to  which 
they  are  subject. 

Pain,  as  a  symptom,  may  occur  in  two  types ;  first,  as  pain  occurring 
at  the  menstrual  period,  i.e.,  dysmenorrhea,  bearing  down  and  cramp- 
like in  character ;  second,  as  a  chronic  aching  pain  in  the  back,  loins,  and 
iliac  regions.  Usually  the  symptoms  of  lumbosacral  backache  date  from 
a  confinement  or  an  abortion.  Dysmenorrhea  is  commonly  the  result  of 
a  febrile  confinement  or  abortion. 

In  that  rare  form  of  chronic  metritis  in  the  nulliparae  due  to  tissue 
hypertrophy,  the  dysmenorrhea  may  date  from  puberty  and  is  evidenced 
by  the  occurrence  of  excessive  uterine  contractions.  Here  the  chronic 
pain  in  the  back  and  iliac  regions  is  constant.  This  is  worse  on  stand- 
ing and  exertion,  due  to  the  drag  of  the  heavy  uterus  on  its  uterosacral 
ligaments.     The  leukorrhea  is  not  a  constant  symptom,  nor  is  it  ordi- 


FIBROSIS  UTERI,  METRITIS,  SUBINVOLUTION  131 

narily  as  distressing-  as  in  the  condition  of  infective  metritis,  except  that 
it  may  be  thin,  acrid  and  irritating  and  produce  an  intractable  pruritus. 

The  differential  diagnosis  of  metritis  must  be  made  from  early  preg- 
nancy, small  fibromyomata,  carcinoma  of  the  uterine  body,  and  uterine 
adenomyoma. 

A  patient  with  chronic  metritis  who  has  recently  become  pregnant 
will  often  give  a  history  of  menorrhagia  with  no  period  of  amenorrhea; 
but  on  close  questioning,  there  is  always  something  atypical. 

A  two  months  pregnant  uterus  is  about  the  size  of  a  chronic  metritic 
uterus,  but  it  intermittently  contracts,  and  is  always  at  some  time  of  softer 
consistence.  Its  shape  changes  on  contraction  and  during  relaxation. 
There  is  some  softening  of  the  cervix,  an  increased  and  changed  secre- 
tion from  the  cervix,  a  dusky  hue  about  the  cervix  and  vaginal  vault,  and 
increased  pulsation  in  the  fornices.  An  Abderhalden  test  may  aid  in  the 
diagnosis. 

A  small  interstitial  fibroid  may  present  extreme  difficulties  in  differ- 
ential diagnosis.  Irregularity  in  contour  points  to  fibromyoma,  a  sound 
may  show  tortuosity  of  the  canal,  and  will  give  an  accurate  appreciation 
of  the  position  of  the  fundus.  Examination  under  anesthesia,  in  stout 
women,  will  aid  in  the  diagnosis.  Hysterotomy  may  be  necessary  to  defi- 
nitely determine  whether  zve  are  dealing  zvith  a  metritis  or  a  tumor. 

The  differentiation  between  metritis  and  carcinoma  of  the  body  is 
the  most  important  diagnosis  the  gynecologist  has  to  make.  No  ques- 
tion of  such  moment  can  be  decided  excefpt  with  the  aid  of  the  curet  and 
a  microscopic  examination  of  the  uterine  scrapings,  by  a  competent 
pathologist. 

Prognosis. — The  prognosis  of  fibrosis,  metritis,  and  subinvolution 
of  the  uterus  is  not  serious  as  tO'  life  but  tends  to  invalid  the  woman, 
owing  to  the  large  and  continuous  blood  loss  which  she  is  forced  to 
sustain.  These  conditions  tend  to  prolong  or  postpone  the  menopause. 
Secondary  anemia,  which  necessarily  follows,  diminishes  her  natural 
resistance  and  makes  her  a  poor  operative  risk,  producing,  as  it  does, 
changes  in  the  heart  muscles  and  kidney  functions. 

Treatment. — The  indications  for  treatment  are : 

(i)     the  control  of  hemorrhage,  and 
(2)     reduction  in  the  size  of  the  uterus. 

Medical  Treatment  Consists  of: 

(a)  rest, 

(b)  hot  douches, 


132  PELVIC  INFLAMMATION  IN  WOMEN 

(c)  vaginal  tamponade 

(d)  galvanism,  and  the 

(e)  administration  of  certain  drugs. 

(a)  Rest. — The  patient  should  remain  in  bed  during  menstruation 
and  have  the  bowels  emptied  with  enemata  and  avoid  excitement  or 
exercise.  Observance  of  these  rules  usually  diminishes  the  amount  of 
blood  lost  and  necessarily  conserves  the  woman's  strength. 

(&)  Hot  Douches. — One  or  two  gallons  of  hot  water,  at  a  tempera- 
ture of  120°  F.,  may  be  used  twice  a  day.  The  douche  is  best  given 
in  the  recumbent  position,  with  the  Davidson  syringe,  to  insure  the 
depletion  of  the  pelvis;  this  changes  the  circulation  in  the  uterus  and 
stimulates  its  contractions. 

(c)  Vaginal  Tamponade  or  Pack. — When  properly  applied  this  will 
temporarilv  control  the  blood  loss,  and  is  the  emergency  method.  The 
patient  should  l)e  in  the  Sims  or  knee-chest  position,  and  the  perineum 
retracted  with  a  Sims  speculum;  then,  after  cleaning  the  vagina  with 
one-half  per  cent  lysol  solution,  the  vagina  is  firmly  packed  with  two 
inch  wide  packing  gauze.  The  gauze  should  be  placed  in  the  fornices, 
against  the  cervix,  and  then  made  to  fill  the  entire  vagina.  Moist  gauze 
controls  hemorrhage  better  than  dry  gauze.  For  when  it  is  placed 
in  position,  it  maintains  its  bulk  and  therefore  maintains  an  even  pres- 
sure. 

(d)  Galvanism. — It  is  claimed  that,  when  the  positive  pole  of  the 
galvanic  current  is  introduced  into  the  cavity  of  the  uterus  and  the 
negative  pole  is  placed  over  the  sacrum  or  pelvis,  the  current  will  stimu- 
late the  uterus  to  contraction  and  thus  relieve  the  circulatory  stasis, 
empty  the  uterine  veins,  and  so  diminish  the  amount  of  the  menstrual 
flow.  Our  experience  with  galvanism  for  the  control  of  hemorrhage 
in  fibrosis  has  not  encouraged  us  to  be  enthusiastic  as  to  its  curative 
value. 

{e)  Drugs. — Of  the  drugs  used  to  check  hemorrhage  in  this  condi- 
tion, thyroid  extract,  pituitary  extract,  ergot  (or  its  derivatives),  styp- 
ticin,  styptol,  etc.,  are  the  ones  in  common  use.  All  have  some  value  in 
controlling  the  bleeding,  but  result  in  no  permanent  cure,  for  the  pathol- 
ogy shows  that  the  minute  changes  in  the  muscle  bundles  and  about  the 
blood  vessels  are  such  that  internal  medication  cannot  produce  any  per- 
manent good.  Only  l)y  removal  of  the  organs,  or  obstruction  of  its  blood 
supply,  can  we  hope  to  permanently  stop  the  hemorrhage. 

Surgical  Treatment. — Under  this  head  we  have  to  consider: 


FIBROSIS  UTERI,  METRITIS,  SUBINVOLUTION  133 

( 1 )  curettage, 

(2)  radium, 

(3)  hysterectomy. 

(1)  Every  woman  of  thirty-five  or  forty  who  presents  herself  with 
anomalous  uterine  bleeding,  after  excluding  the  possibility  of  a  condition 
of  the  pregnant  state,  is  entitled  to  a  diagnostic  curettage;  for,  only  by 
a  microscopic  examination  of  the  removed  endometrium  can  a  positive 
diagnosis  be  made  of  the  benignancy  or  malignancy  of  the  uterine  en- 
largement. 

Curettage  of  the  uterus  will  temporarily  check  the  hemorrhage  of 
fibrosis  or  subinvolution;  for  some  part  of  the  bleeding  comes  from  the 
hypertrophied  endometrium  so  frequently  present  in  the  early  stages 
of  this  condition.  But,  as  the  actual  cause  of  the  hemorrhage  is  not 
in  the  thickened  endometrium,  or  the  atrophy  of  the  glands,  with  changes 
in  the  gland  products,  but  in  the  histologic  changes  in  the  uterine  walls 
and  in  and  about  the  blood  vessels,  little  curative  value  can  be  expected 
from  removing  the  endometrium  with  the  curet.  After  curettage  the 
woman  may  not  bleed  for  one  or  two  periods,  and  then  the  hemorrhage 
will  return  as  a  menorrhagia  or  metrorrhagia,  or  both,  often  with  in- 
creased severity. 

(2)  Radium  will  control  the  hemorrhage  from  fibrosis,  m£tritis, 
and  subinvolution  in  one  hundred  per  cent,  of  selected  cases  and  reduce 
the  size  of  the  uterus  to  that  of  the  senile  organ;  unfortunately,  not 
all  cases  of  fibrosis,  metritis,  and  subinvolution  are  amenable  to  cure 
by  radium,  and  its  use  is  contra-indicated  in  pelves  which  have  previously 
been  the  seat  of  extensive  inflammatory  processes,  pelvic  peritonitis, 
chronic  salpingitis,  etc.  However,  if  the  large,  smooth,  hard,  uterus 
is  freely  movable  and  shows  no  para-  or  perimetrial  or  adnexal  compli- 
cations, radium  may  be  safely  used,  and  used  with  a  knowledge  that  by 
an  irradiation  of  twenty  to  twenty-four  hours  the  hemorrhage  will  be 
checked,  the  leukorrhea  will  cease,  and  the  uterus  will  atrophy. 

No  anesthetic  is  necessary,  but  the  patient  is  given  a  third  of  a  grain 
of  morphia  hypodermatically  one  hour  before  introducing  the  radium; 
and,  after  the  vulva,  vagina,  and  cervical  portio  have  been  properly 
prepared,  the  woman  is  placed  in  the  lithotomy  position  and  the  cervix 
carefully  dilated  with  Hegar's  sounds  to  a  size  sufficient  to  allow 
the  introduction  of  the  radium  capsule.  Fifty  to  seventy-five  milligrams 
of  the  radium  salt,  incased  in  a  capsule  of  glass,  an  envelope  of  silver, 
and  a  brass  filter,  to  remove  the  irritating  (3  rays  of  the  radium,  are 
now  introduced  into  the  uterine  cavity  and  retained  in  the  uterus  by  plac- 


134  PELVIC  INFLAMMATION  IN  WOMEN 

ing  a  narrow  gauze  pack  in  the  cervix,  which  in  turn  is  supported  by  a 
firm  gauze  vagina  pack.  This  technic  prevents  the  expulsion  from  the 
uterus  of  the  radium  capsule  before  the  time  for  its  withdrawal,  and 
thus  prevents  burning  of  the  vagina,  as  well  as  the  danger  of  its  ex- 
pulsion and  loss. 

The  radium  should  be  removed  in  twenty  to  twenty-four  hours,  as 
1,000-1,500  milligram  hours  are  sufficient  to  check  most  uterine  hem- 
orrhages occurring  from  this  cause;  following  the  removal  of  the 
radium,  there  is  a  serosanguinous  discharge  from  the  cavity  of  the  uterus. 
This  continues  for  five  or  six  days,  when  the  character  changes  to  a  sero- 
purulent  leukorrhea,  which  entirely  ceases  in  the  course  of  three  weeks. 
In  two  months  time  the  size  of  the  uterus  will  have  diminished  to 
one-half  the  size  it  was  prior  to  the  irradiation,  and  in  six  months 
it  will  be  senile,  unless  there  are  intramural  or  subperitoneal  fibromata 
in  the  walls. 

Kelly,  Clark,  and  Miller  all  endorse  this  treatment  of  hemorrhages 
due  to  subinvolution  or  fibrosis  by  the  application  of  radium  to  the 
interior  of  the  uterine  body. 

(3)  In  the  light  of  our  present  day  pathology,  the  field  for 
hysterectomy,  in  the  cure  of  subinvolution,  metritis,  and  fibrosis,  is 
limited  to  those  cases  where  there  exists  extensive  actual  trauma  of 
the  cervix  or  lower  uterine  segment,  and  those  cases  where  the  woman 
has  been  the  subject  of  subacute  or  chronic  pelvic  inflammation,  with 
recurring  exacerbations.  Such  cases  not  only  drain  the  woman's  vitality 
by  repeated  bleeding,  but  render  her  an  invalid  with  pelvic  distress. 

Total  hysterectomy  should  be  done,  in  order  that  all  foci  of  infection 
in  the  cervix  may  be  removed,  but  as  these  patients  usually  have  a 
higher  blood  pressure  than  other  women  of  their  age,  we  feel  it  is  im- 
portant to  co'uscrve  the  ovarian  function,  for  total  removal  of  the  sex 
glands  breaks  the  harmonious  and  interdependent  relation  of  the  internal 
secretions  and  subjects  the  woman  to  increased  nervous  phenomena, 
brought  about  by  the  uncurhed  action  of  the  thyroid,  adrenal,  and 
pituitary  glands. 


CHAPTER  VII 

SALPINGITIS 

Four  routes  of  infection — Sepsis  and  gonorrhea  the  most  common  causes  of  sal- 
pingitis— Acute  salpingitis — Hydrosalpinx — Clinical  phenomena — Significance  of 
the  history — Dififerential  diagnosis — Physical  signs  of  pyosalpinx — Hydrosalpinx 
— Hematosalpinx — Gonorrheal  salpingitis — Treatment  of  acute  salpingitis — Tech- 
nic  of  vaginal  section  (posterior  colpotomy) — Treatment  of  chronic  salpingitis — 
Salpingostomy — Technic    of    salpingectomy — Radical    treatment — Technic. 

Salpingitis  is  an  inflammation  of  the  fallopian  tube,  which  is  nearly 
always  secondary  to  infection  of  the  uterus  or  of  the  peritoneum. 

The  infecting  organisms  may  reach  the  tube  by  four  different 
routes. 

1.  They  may  gain  access  to  the  lumen  of  the  tube  from  the  in- 
terior of  the  uterus,  as  in  acute  gonorrheal  infection  of  the  endometrium. 

2.  They  may  reach  the  tube  from  the  peritoneal  cavity  by  way  of 
the  abdominal  ostium,  as  in  streptococcic  and  staphylococcic  cellulitis 
and  peritonitis,  following  childbirth  and  abortion.  By  this  route  the 
bacteria  may  be  sucked  in  from  the  peritoneum  by  the  ciliary  current  at 
the  ostium,  in  which  case  the  tubal  infection  is  secondary  to  the  peri- 
tonitis, or  they  may  produce  an  endosalpingitis  by  extension  through  the 
lymph  channels  of  the  broad  ligament. 

3.  They  may  gain  access  through  the  tube  wall,  when  intestinal 
adhesions  are  present,  as  in  the  peritonitis  following  appendicular  and 
intestinal  perforations. 

4.  And  finally,  bacteria  may  invade  the  tube  through  the  blood 
stream  or  lymph  channels,  as  is '  the  case  in  primary  tuberculous  sal- 
pingitis. 

Sepsis  and  gonorrhea  are  the  most  com  Dion  causes  of  tubal  inflam- 
mation, and  various  microorganisms  may  be  found.  The  gonococcus 
is  the  organism  most  frequently  met  zvitli,  producing  from  forty  to  fifty 
per  cent  of  all  tubal  infcctioiis.  The  infection  in  these  cases  always 
ascends  from  the  interior  of  the  uterus.  Infection  by  the  streptococcus 
and  staphylococcus  is  also  generally  an  invasion  from  below.  These 
bacteria  excite  a  marked  inflammatory  reaction,  causing  a  seroplastic 
exudate,  which  is  poured  out  by  the  perisalpinx  and  peritoneum,  with 

135 


136  PELVIC  INFLAMMATION  IN  WOMEN 

formation  of  adhesions  to  the  adjacent  bowel.  This  in  turn  permits 
a  secondary  infection  by  the  colon  bacillus. 

Salpingitis  occurring  before  puberty  is  always  gonorrheal  or  tuber- 
culous in  origin,  although  it  is  possible  for  a  child  to  have  salpingitis 
following  the  exanthemata.  The  inflammation  is  usually  bilateral,  al- 
though one  tube  may  be  involved  at  a  time,  and  each  may  have  a  diiiferent 
pathology.  Owing  to  the  anatomical  relations  of  the  tube,  it  is  seldom 
that  a  salpingitis  remains  localized.  It  becomes  a  part  of  an  inflammation 
of  the  pelvic  tissues,  the  infection  extending  to  the  adjacent  ovaries, 
peritoneum,  and  contiguous  pelvic  structures.  Not  until  the  infection 
becomes  subacute  or  chronic  can  the  tubal  pathology  be  definitely  iden- 
tified. 

Acute  Salpingitis. — It  has  already  been  stated  that  the  infecting 
organism  may  be  the  gonococcus,  the  streptococcus,  the  pneumococcus, 
or  the  colon  bacillus,  either  alone  or  in  combination.  Mixed  infections 
have  the  most  serious  effect  and  produce  the  greatest  tissue  reaction  in 
the  tubal  structures,  and  inzfariahly  leaz'e  some  permanent  pathology. 

Pathology. — The  invading  organism  first  excites  an  inflammatory 
reaction  in  the  tubal  mucous  membrane,  but  finally  all  the  coats  of  the 
tube  become  involved.  The  mucosa  becomes  swollen  and  edematous, 
and  there  is  a  hypersecretion  of  mucus;  serum  is  poured  out  into  the 
underlying  tissues,  the  surface  epithelium  proliferates,  and,  if  the  in- 
flammation continues,  dies  and  desquamates;  as  a  consequence,  in  the 
ampulla  and  infundibulum,  the  folds  become  so  thickened  that  they 
impinge  upon  each  other,  and  the  plicae,  devoid  of  their  epithelium, 
adhere  to  one  another  and  practically  block  the  lumen.  Coincidentally, 
the  muscular  and  peritoneal  coats  of  the  tube  become  edematous  and 
infiltrated  with  inflammatory  cells,  and  the  fimbriated  extremity  is 
swollen;  so  that,  at  this  time,  histologic  examination  of  the  tube  will 
show  not  only  an  endosalpingitis,  but  a  myosalpingitis  and  perisalpingitis. 

The  edema  and  infection  of  the  peritoneal  coat  causes  swelling  of 
the  endothelial  cells,  and  a  serous  or  plastic  exudate  is  poured  out  on  the 
serosal  surface,  which  leads  to  the  formation  of  visceral  adhesions. 

The  swelling  of  the  mucosa  of  the  fimbria  may  cause  an  inversion 
of  the  fimbria  and  adhesion  of  their  peritoneal  surfaces,  thus  closing  the 
abdominal  ostium;  or,  there  may  be  pouting  of  the  mucosa,  which  will 
prevent  complete  closure  of  the  abdominal  end,  and  thus  allow  the 
infection  to  spread  to  the  adjacent  peritoneum  and  ovary;  or,  an  exuda- 
tion, with  adhesions  between  the  tube  and  ovary,  and  between  the  tube 
and  adjacent  bowel,  or  with  the  pelvic  peritoneum  resulting.  Adhesion 
always  more  or  less  completely  closes  the  lumen  and  temporarily  checks 


SALPINGITIS 


137 


the  infective  process.  Closure  of  the  abdominal  ostium  by  adhesion  of 
the  peritoneal  surfaces  of  the  fimbria,  or  by  adhesion  to  adjacent  struc- 
tures, always  distorts  and  displaces  the  tube. 

The  most  common  displacement  of  the  tube  is  downward,  where 
it  becomes  adherent  to  the  posterior  surface  of  the  broad  ligament,  or 
attached,  in  the  cul  de  sac  of  Douglas,  to  the  uterosacral  ligament.  As 
it  drops  downward  and  backward  and  inward,  it  envelops  the  ovary, 
burying  it  between  the  posterior  surface  of  the  broad  ligament  and  the 
mesosalpinx.     The  nearby  pelvic  structures  are  often  involved  in  the 


Fig.   43. — A    Pyosalpinx    Showing    How    the   Tube    Rolls    Over  the  Ovary  and 

Drops  into  the  Cul  de  Sac. 


infection,  especially  the  ovary,  and  secondary  collections  of  pus  may 
form  in  the  peritoneum.  Most  pelvic  inflammations  originate  in  puru- 
lent salpingitis. 

To  naked  eye  inspection,  the  tube  is  thicker,  more  tortuous,  and  of  a 
brighter  red  color  than  normal.  If  the  fimbriated  end  is  free,  pus  may 
be  seen  escaping  from  the  abdominal  ostium. 

The  termination  of  acute  salpingitis  may  be  in  resolution,  as  the 
inflammation  may  subside  completely,  leaving  behind  only  a  slight 
fibrous  thickening  of  the  tube  wall  and  a  few  adhesions  about  the 
fimbriated  extremity. 

In  our  experience,  gonorrheal  infections,  uncomplicated  by  other 
cocci,  frequently  terminate  in  complete  regeneration  of  the  tube.  Several 
of  our  cases  have  subsequently  become  pregnant  and  have  been  delivered 


138  PELVIC  INFLAMMATION  IN  WOMEN 

of  healthy  children.  The  tubal  inflammations  which  complicate  post- 
partal  or  postabortal  infections,  particularly  those  in  which  cellular  or 
peritoneal  inflammations  have  been  present,  are  not  apt  to  regenerate  so 
completely.  Mixed  infections  take  longer  to  subside  and  always  perma- 
nently damage  the  tube.  Pregnancy  is  unlikely  to  follow  in  this  group. 
Sterility  is  the  rule. 

In  other  cases,  as  the  result  of  the  desquamation  of  the  surface  epi- 
thelium, adhesions  may  form  between  the  plicae  uniting  the  folds  of 
mucous  membrane;  this  narrows  the  lumen  of  the  tube,  or  may  even 
cause  a  complete  obstruction,  so  that  the  tube  may  be  divided  into 
several  compartments,  each  containing  pus. 


Fig.  44. — Double  Hydrosalpinx  from  the  Author's  Collection. 

The  acute  inflammation  may  pass  into  a  subacute  or  chronic  in- 
flammation, and,  as  a  result,  the  walls  of  the  tube  become  greatly 
thickened;  therefore,  it  may  be  increased  in  thickness  to  the  size  of 
the  thumb  and  become  tortuous,  or  the  lumen  may  be  dilated  and  filled 
with  mucoid  or  purulent  contents.  In  other  words,  a  sactosalpinx  is 
formed  which  may  contain  serum  and  mucus,  blood  or  pus.  These 
tubal  swellings  result  from  closure  of  the  abdominal  ostium  by  adhesion 
of  the  peritoneal  surface  of  the  fimbriae,  or  by  adhesive  attachment  of 
the  fimbriae  to  the  peritoneum  or  ovary ;  in  either  event,  to  form  a  sacto- 
salpinx, the  abdominal  end  must  be  closed.  Such  closure  may  in  time 
result  in  a  hydrosalpinx  or  pyosalpinx. 

A  hydrosalpinx  is  a  thin  walled,  translucent,  retort  shaped  tumor  con- 
taining a  serous  accumulation.  The  outer  end  of  the  tube  is  always 
closed ;  the  uterine  end  may  or  may  not  be  patent. 


SALPINGITIS 


139 


The  narrow  isthmic  portion  next  to  the  uterus  is  practically  undilated 
and  remains  of  comparatively  normal  thickness.  There  is,  however, 
always  a  cell  proliferation  into  the  muscle  about  the  isthmic  or  inter- 
stitial portions,  forming  the  so-called  "isthmic  node."  The  ampulla  and 
infundibulum  more  readily  dilate,  hence  the  (retort  shaped)  form  of 
these  tubal  sacs.  Tubes  distended  in  this  way  may  attain  a  very  large 
size,  forming  tumors  the  size  of  a  grape  fruit  or  larger,  or  they  may 
intermittently  empty  themselves  through  the  uterus. 

As  a  result  of  intestinal  adhesions  to  the  tube,  there  is  often  a  sec- 
ondary infection  by  the  bacillus  coli ;  when  this  occurs,  the  original  infect- 
ing organism  frequently  dies  out,  and  after  a  time  the  bacillus  coli  also 


Fig.  45. 


-Specimen  of  Pyosalpinx  from  the  Author's  Collection  Showing  Inflam- 
matory Nodes  in  the  Isthmus. 


dies,  and  there  is  left  a  tube  distended  with  pus,  often  foul  smelling,  but 
sterile.  These  puiulent  accumulations  within  the  tube  are  called  pyo- 
salpinx. The  fact  that  the  pus  in  these  cases  may  become  sterile,  is  of 
great  clinical  importance,  as,  not  infrequently,  during  the  removal  of 
such  a  tumor,  more  or  less  of  its  content  is  spilled  over  the  peritoneal 
surface ;  but,  as  the  contained  pus  is  sterile  in  from  sixty  to  seventy  per 
cent  of  the  cases,  the  soiling  gives  rise  to  little  or  no  trouble. 

Hyde's  work  has  shown  that  in  gonorrheal  infections  the  contained 
pus  is  sterile  in  from  six  zveeks  to  three  months,  but  the  streptococcus 
may  live  in  the  tissues  for  years.  Operation  on  these  tubes  of  strep- 
tococcic origin  is  always  serious,  as  the  liberation  of  the  cocci  may  excite 
a  fatal  streptococcic  peritonitis,  while  gonorrheal  infection  tends  to  re- 
main localized  within  the  pelvic  basin. 

The  tube  may  become  adherent  and  rupture   into   the  peritoneal 


140 


PELVIC  INFLAMMATION  IN  WOMEN 


cavity  or  into  the  adjacent  viscera.  Rupture  into  the  peritoneal  cavity  is 
always  attended  with  the  symptoms  and  physical  signs  of  an  abdominal 
calamity,  i.e.,  severe  abdominal  pain,  shock  and  evidence  of  peritoneal 
reaction,  as  shown  by  tension,  tenderness,  tympany  and  a  high  leukocyte 
count,  together  with  a  high  polymorphonuclear  percentage ;  or,  the  escap- 
ing pus  may,  as  the  result  of  adhesions,  become  encysted  in  the  true  pelvis 
and  form  a  pelvic  abscess. 

Clinical  Phenomena. — The  mode  of  onset  varies  with  the  nature 
and  virulence  of  the  infecting  organism.  In  some  cases  it  is  very 
sudden,  while  in  others  the  onset  is  more  gradual.  There  is  acute  pain 
in  the  lower  abdomen,  sometimes  in  the  midline,  but  more  often  in  the 


Fig.  46. — Suppurative  Salpingitis  on  One  Side  with  a  Pyosalpinx  on  the  Othek. 

lower  quadrant  over  the  side  affected.  The  pulse  is  increased  in  rate  and 
there  is  an  elevation  of  the  temperature.  Owing  to  the  muscular  spasm 
over  the  affected  tube,  the  lower  abdomen  does  not  move  with  respiration 
as  freely  as  normal  and,  as  a  consequence,  there  are  "still  areas"  over  this 
region  ahd  tension  and  tenderness  on  palpation.  In  acute  cases  it  is  diffi- 
cult to  dissociate  the  symptoms  of  salpingitis  from  those  of  the  acute 
endometritis  and  peritonitis  accompanying  the  tubal  infection. 

The  Significance  of  History. — The  antecedent  history  of  urethri- 
tis or  of  recent  marriage  and  the  occurrence  of  leukorrhea  is  as  suggestive 
of  gonorrhea,  as  the  history  of  labor  or  abortion  is  of  sepsis. 

Symptoms. — Often  the  systemic  disturbance  is  marked  at  the  onset. 
There  is  sudden  pelvic  and  abdominal  pain  and  a  rise  of  pulse  and  tem- 
perature proportionate  to  the  virulence  of  the  local  process.  Frequently 
the  symptoms  of  general  acute  pelvic  inflammation  make  an  anatomical 
diagnosis  impossible;  but  as  the  acute  process  subsides,  a  more  exact 
"geographical"  location  of  the  primary  focus  can  be  made.  There  is 
always  a  mucopurulent  leukorrhea,  for  the  circulatory  stasis  in  the  uterus 
and  cervix  persists^  until  all  of  the  contiguous  exudate  has  disappeared. 


SALPINGITIS  141 

Furthermore,  the  cervix  remains  swollen  and  sensitive  for  a  long  period 
and,  in  consequence  its  infected  glands  pour  out  an  excessive  muco- 
piirident  discharge.  This  leukorrhea  is  accompanied  by  pain  and  tender- 
ness in  the  region  of  the  affected  tube,  and  this  is  more  marked  when 
the  exudate  in  the  peritoneum  includes  the  ovary.  The  paiji  is  often 
intermittent  or  colicky  and  depends  somewhat  on  the  state  of  the  intestinal 
tract.  Intestinal  activity  always  increases  the  pain.  There  is  lumbo- 
sacral backache  because  of  the  involvement  of  the  peritoneum  covering 
the  uterosacral  ligaments. 

There  may  be  dysuria  and  dyschesia,  the  latter  being  dependent  upon 
the  extent  of  the  peritoneal  exudate  and  the  position  of  the  tubal  tumor. 
As  the  uterosacrals  are  always  involved  in  tubal  inflammations,  one  can 
readily  see  how,  as  the  fecal  mass  passes  between  these  swollen  cellular 
bands,  defecation  may  become  exceedingly  painful. 

Menstruation  is  disturbed,  owing  to  the  increased  congestion  coin- 
cident with  the  parametrial  and  perimetrial  inflammation.  The  bleed- 
ing may  be  too  frequent  or  too  profuse,  and  is  always  attended  with  pre- 
menstrual and  comenstrual  pain.  There  is  usually  over  the  lower  ab- 
domen a  premenstrual  soreness,  which  is  due  to  the  chronic  peritoneal 
irritation.  If  the  tumor  mass  is  large  or  the  peritoneal  exudate  extensive, 
vesical  and  rectal  tenesmus  is  added  to  the  symptom  complex. 

Intestinal  tympany  is  more  or  less  constant  in  all  acute  and  subacute 
tubal  inflammations,  owing  to  the  frequency  of  ileal,  colonic,  and  sig- 
moidal  adhesions,  which  produce  paretic  areas  and  interfere  with  normal 
peristalsis. 

In  chronic  cases  leukorrhea,  premenstrual  pain,  dyspareunia,  and 
sterility,  alone  or  in  combination,  are  the  symptoms  for  which  the  patient 
seeks  relief.  All  of  the  symptoms  are  aggravated  by  walking  and 
standing. 

Recurrent  attacks  of  pelvic  peritonitis  are  characteristic  of  subacute 
tubal  inflammation  and  occur  most  frequently  at  or  near  the  menstrual 
periods.  These  exacerbations  are  comparatively  common  in  the  early 
stages  of  chronic  salpingitis,  as  in  many  cases  the  abdominal  ostium 
is  not  entirely  closed  and  leakage  occurs,  thus  setting  up  renewed  reac- 
tions in  the  adjacent  peritoneum.  Ultimately,  however,  the  abdominal 
ostium  becomes  sealed  by  inversion  of  the  fimbriae  or  by  adhesions  to 
the  contiguous  ovary  or  peritoneum,  and  then  the  tube  becomes  quiescent. 
With  these  local  symptoms  there  is  general  debility,  loss  of  weight, 
digestive  and  nervous  disturbances.  Continued  local  pain  and  infection 
not  only  cause  general  discomfort,  but  are  bound  to  undermine  the  gen- 
eral health  of  the  woman. 


142  PELVIC  INFLAMMATION  IN  WOMEN 

Leukorrhea,  menstrual  disturbances,  dysmenorrhea,  sterility,  and  in- 
termenstrual pain  are  the  principal  symptoms.  The  pelvic  pain  usually 
subsides  when  the  menstrual  flow  has  become  established. 

The  symptoms  are  not  necessarily  marked  in  chronic  infection  of 
the  tubes,  for  time  effects  a  symptomatic  cure  in  a  large  number  of  cases. 

Physical  Signs. — On  abdominal  examination,  in  the  acute  stage 
there  will  be  some  distention  with  tension  and  tenderness  on  pressure  over 
the  lower  quadrants.  After  the  acute  stage  has  passed,  we  may  find 
nothing  except  moderate  intestinal  distension  and  tenderness  on  pres- 
sure over  Morris's  points.  Tenderness  over  both  Morris's  points  is  al- 
ways significant  of  pelvic  inflammation,  for  the  lymphatic  drainage 
from  the  tubes  is  directed  into  the  lumbar  glands,  along  the  vertebral 
column,  over  which  these  points  are  located. 

On  abdomxinovaginal  or  abdominorectal  examination,  the  tube  or 
tubal  mass  may  usually  be  found  as  a  thickened  tender  tumor  at  the  side 
of  and  frequently  behind,  rarely  in  front  of,  the  uterus.  It  is  generally 
fixed.  The  uterus  is  larger  than  normal  and  more  or  less  fixed  by  the 
associated  pelvic  peritonitis  and  uterosacral  parametritis,  which  are 
usually  constant  in  all  tubal  inflammations.  This  explains  the  pain  caused 
by  moving  the  uterus.  The  tube  and  ovary  and  often  all  of  the  other 
pelvic  contents  are  so  matted  together  into  one  conglomerate  mass,  that 
an  anatomic  diagnosis  from  the  physical  findings  is  absolutely  impossible. 

In  tuberculous  salpingitis  there  may  be  evidence  of  tuberculosis  in 
other  organs,  or  the  tubercle  bacilli  may  be  found  in  the  uterine  dis- 
charge. Usually  however  the  diagnosis  cannot  be  made  until  the  tube 
is  removed  and  its  contents  examined  and  microscopic  study  made  of  sec- 
tions taken  from  the  diseased  areas. 

Differential  Diagnosis. — It  is  sometimes  difficult  to  differentiate 
right  sided  tubal  inflammation  from  appendicitis,  for  abdominal  opera- 
tion has  shown  that  appendectomy  has  been  performed  in  ten  to  fifteen 
per  cent  of  cases  where  tubal  disease  is  the  existing  pathology.  This  is 
readily  understood  when  we  remember  that  the  appendix  may  become 
adherent  in  the  pelvis,  and  thus  become  a  complicating  factor  in  pelvic 
inflammation. 

In  appendicitis,  both  the  history  and  physical  signs  are  so  definite 
that,  if  proper  credence  he  given  to  them  and  their  sequence  is  duly  con- 
sidered, it  would  appear  that  a  differential  diagnosis  should  be  possible  in 
almost  every  case. 

J.  B.  Murphy,  in  a  study  of  two  thousand  cases  of  acute  appendicitis, 
found  that  the  symptom  sequence  was  always  as  follows :  acute  alxlomi- 
nal  pain,  most  frequently  referred  to  the  region  of  the  umbilicus  or 


SALPINGITIS  143 

epigastrium,  followed  by  vomiting,  the  vomitus  consisting  of  the  contents 
of  the  stomach;  this  in  turn  is  followed  by  local  pain  in  the  region  of  the 
appendix  and  a  slight  rise  in  temperature  and  pulse  rate. 

Physical  examination  at  this  time  will  show  tension  and  tenderness  in 
the  right  lower  quadrant,  with  accentuated  tenderness  over  both  Mc- 
Burney's  and  Morris's  points  (right).  The  blood  count  always  shows 
a  leukocytosis  with  a  relatively  high  polymorphonuclear  percentage. 

When  this  sequence  did  not  occur.  Murphy  found  that  the  abdominal 
condition  was  due  to  some  other  lesion  than  an  inflamed  appendix. 
Further  diagnostic  aid  may  be  had  by  making  dozvnward  pressure  with 
the  hand  over  the  colon,  gently  forcing  the  cecal  contents  toward  the  ap- 
pendix. This  always  causes  pain  in  appendicitis.  Tenderness  over  the 
right  Morris  point,  which  is  located  one  inch  and  a  half  below  and  one 
inch  to  the  right  of  the  umbilicus,  over  the  lumbar  glands,  is  also  sugges- 
tive in  appendicitis.  While  sensitiveness  at  Hank's  point,  which  is  sit- 
uated an  inch  and  a  half  to  the  right  and  an  inch  above  the  umbilicus, 
being  also  over  the  lumbar  glands,  is  found  to  be  present  in  most  cases 
of  appendicitis. 

Muscular  tension  is  generally  more  marked  in  the  presence  of  appen- 
diceal inflammation  than  in  an  inflammation  of  pelvic  origin. 

On  the  other  hand,  in  acute  tubal  inflammation,  or  in  acute  exacer- 
bations of  chronic  pelvic  inflammation  there  is  a  different  history.  There 
is  usually  an  antecedent  history  of  gonorrhea,  evidenced  by  urethritis  or 
profuse  leukorrheal  discharge,  or  of  recent  labor  or  abortion.  The 
muscular  rigidity  is  less  marked  and  less  well  defined,  and  tenderness  may 
usually  be  elicited  over  both  Morris's  points.  The  temperature  is  apt  to 
be  higher,  but  the  patient  less  ill  than  in  appendiceal  infection. 

The  leukocyte  count  may  show  a  high  total  white,  but  unless  there 
has  been  tubal  rupture,  with  spreading  peritonitis,  the  percentage  of 
polymorphonuclears  is  relatively  low.  By  vagino-abdominal  examina- 
tion the  tube  may  usually  be  found  as  a  thickened,  sensitive  mass,  to 
the  side  of,  or  behind  the  uterus. 

In  the  very  early  stages  of  acute  salpingitis,  before  an  extensive 
exudate  is  poured  out,  there  may  be  no  palpable  mass,  though  there  is 
exquisite  sensitiveness  in  the  posterior  and  lateral  fornices.  The  uterus, 
however,  is  always  exquisitely  sensitive  to  motion,  because  of  the  para- 
metritis and  localized  peritonitis,  which  coexists  in  some  degree  in  all 
tubal  infections. 

It  would  seem  hardly  possible  for  gallbladder  inflammation  to  so 
simulate  salpingitis  as  to  make  a  differentiation  necessary.  When  the 
gallbladder  is  involved,  there  is  sudden  abdominal  pain  referred  to  the 


144  PELVIC  INFLAMMATION  IN  WOMEN 

epigastrium  and  vomiting  follows,  which  is  more  or  less  persistent,  de- 
pending upon  the  degree  of  peritoneal  irritation  present.  The  tempera- 
ture is  not  much  elevated,  except  in  empyema,  in  which  instance  it  may 
reach  102-104.5°  F.  There  is  tension  of  the  right  rectus  below  the  costal 
margin,  and  tenderness  over  Mayo-Robson's  point.  Finally,  if  we  have 
the  patient  sit  up  and  lean  forward,  and  the  fingers  of  one  hand  are 
pressed  in  under  the  costal  margin  of  the  liver,  the  patient  will,  on  taking 
a  deep  inspiration,  complain  of  exquisite  tenderness. 

Nephrolithiasis  and  ureterolithiasis  may  be  excluded  by  examination 
of  the  urine,  catheterization  of  the  ureters,  marking  of  the  wax  tipped 
ureteral  bougie,  and  the  X-ray  examination  of  the  kidney  and  ureter. 

Physical  Signs  of  Pyosalpinx. — In  pyosalpinx  the  tube  forms  a  ■ 
tumor  which  varies  in  size  from  that  of  the  finger  (8x6x2  cm.)  to  that 
of  the  fist  (28  to  30  cm.  in  circumference).  Because  of  its  weight  and 
primary  downward  displacement,  it  is  usually  situated  behind  and  beside, 
rarely  in  front,  of  the  uterus.  It  may  be  sausageshaped,  lying  obliquely 
in  the  cid  de  sac  behind  and,  depending  upon  its  size,  displacing  the 
uterus  forward,  upward,  or  to  one  side.  It  may  fluctuate  or  be  cystic  in 
character,  or  it  may  be  as  dense  as  a  fibroid,  or  the  pelvis  may  be  partly 
or  wholly  filled  with  a  hard  board-like  exudative  mass,  which  has  none 
of  the  characteristic  signs  of  a  tubal  tumor.  This  is  especially  true 
during  acute  exacerbations  of  subacute  or  chronic  pelvic  inflammation. 
The  uterus  is  enlarged,  more  or  less  firmly  fixed  and  displaced,  upward, 
downward  or  laterally,  depending  upon  the  size  and  location  of  the 
mass,  or  the  tube  and  uterus  may  be  so  matted  together  that  neither  is 
distinguishable  in  the  general  pelvic  mass. 

Recto-abdominal  or  vagino-abdominal  examination,  particularly  un- 
der surgical  anesthesia,  is  useful  in  detecting  and  mapping  out  the  tumor 
and  distinguishing  it  from  the  contiguous  organs,  to  which  it  is  always 
adherent. 

Differential  Diagnosis  of  Pyosalpinx. — We  have  to  distinguish  a 
pyosalpinx  from  appendicular  abscess,  parametritic  abscess,  fecal  tumors, 
tubal  pregnancy,  hydro-  and  hematosalpinx,  and  ovarian  tumors. 

Ovarian  tumors  are  generally  more  nearly  globular  and  not  so  closely 
connected  with  the  uterus.  Under  anesthesia  there  is  usually  a  sharp 
line  of  separation  which  can  be  made  out  between  the  cyst  and  the 
uterus.  Large  ovarian  tumors  are  more  readily  recognized  by  their  size, 
consistency,  and  absence  of  inflammatory  signs. 

Tubal  pregnancy,  as  a  rule,  can  be  diagnosticated  by  its  typical  his- 
tory and  the  alisence  of  an  exudative  mass. 

Fecal  tumors  are  recognized  by  the  "pitting"  which  can  be  made  in 


SALPINGITIS  145 

the  mass,  on  pressure  by  the  finger,  through  the  vaginal  wall  or  by  rectal 
exploration  and  by  enemata. 

A  parametritic  abscess  usually  displaces  the  uterus  upward  and  to  one 
side,  while  pyosalpinx  displaces  forward  and  to  one  side.  Parametric 
abscess  always  follows  lalx)r,  abortion,  or  intra-uterine  instrumentation, 
and  is  so  intimately  blended  with  the  uterus,  that  the  lateral  fornix,  owing 


Fig.  47. — A  Pyosalpinx  on  One  Side  and  a  Tubo-ovarian  Abscess  on  the  Other. 
From  the  Author's  Collection. 

to  the  swelling  in  the  parametrial  connective  tissue,  is  efifaced  and  the 
cervix  is  flush  with  the  vaginal  vault. 

Hydrosalpinx  presents  the  greatest  difficulty  in  differential  diagnosis. 
In  hydrosalpinx  the  pain,  tenderness,  and  systemic  disturbances  are  less 
marked  than  in  pyosalpinx.  The  walls  are  thin  and  more  fluctuant,  and 
the  tumor  may  even  be  so  flaccid  as  not  to  be  appreciable  to  the  bimanual 
touch. 

Hematosalpinx,  the  result  of  tubal  pregnancy,  is  distinguished  by  its 
abrupt  development,  the  characteristic  metrorrhagia,  and  the  physical 
signs.  In  acute  inflammatory  conditions  within  the  pelvis  satisfactory 
bimanual  examination  is  often  impossible  without  general  surgical  anes- 
thesia, owing  to  the  exquisite  pain  produced  by  the  manipulation,  and 


146  PELVIC  INFLAMMATION  IN  WOMEN 

examination  at  this  time  almost  invariably  increases  the  inflammatory 
reaction.  Even  under  the  most  favorable  circumstances  a  definite  differ- 
ential diagnosis  is  not  always  possible. 

Appendicular  abscess  is  usually  suggested,  if  a  careful  history  is 
noted,  but  when  it  has  formed  in  conjunction  with  a  pelvic  peritonitis, 
adhesions  may  make  the  diagnosis  more  difficult.  With  appendicular 
abscess,  on  abdominal  palpation,  we  find  the  uterus  to  be  free  and,  for 
the  most  part,  insensitive  and  freely  movable.  Recto-abdominal  exami- 
nation may  show  the  abscess  to  be  situated  close  to  the  pelvic  brim  pos- 


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Fig.  48. — Acute  Red  Degeneration  of  a  Myoma  Complicating  Pregnancy.  Sudden 
Onset,  Acute  Pelvic  and  Abdominal  Pain  and  Fever  Rise  in  Pulse  and  Leuko- 
cytosis, WITH  Rapid  Increase  in  Size  of  Tumor  Mass,  which  Became  Ex- 
quisitely Sensitive,  Simulating  an  Acute  Abdomen. 

teriorly.  Occasionally  a  point  of  induration  is  found  over  the  abscess 
area,  and  this  may  point  to  its  true  location. 

Prognosis. — Probably  in  no  other  pelvic  condition  is  the  prognosis 
so  dependent  on  an  intelligent  appreciation  of  the  life  history  of  the 
infecting  organism  and  the  pathology  which  it  produces,  as  in  inflamma- 
tion of  the  fallopian  tubes.  In  pure  gonorrheal  infection  of  the  tube, 
time  will,  in  a  large  majority  of  the  cases,  allow  a  complete  recuperation 
of  the  tube.  Mixed  infections  are  not  so  favorable  in  their  end  results, 
for  pyosalpinx  is  almost  invariably  the  terminal  condition  of  a  mixed 
infection,  while  hydrosalpinx  is  a  terminal  result  of  streptococcic  infec- 
tion, reaching  the  tube  by  way  of  the  parametrium  and  peritoneum. 

Both  pyosalpinx  and  hydrosalpinx  are  terminal  conditions,  the  fin- 


SALPINGITIS  147 

ished  products  of  the  inflammation,  and,  unless  manifestations  are  ex- 
cited by  further  bacterial  invasion,  as,  for  instance,  from  the  intestine 
or  through  the  uterus  by  untimely  instrumentation  near  a  menstrual 
period,  these  conditions  may  remain  quiescent  for  a  long  period  of  time. 

Purulent  salpingitis  terminates  most  frequently  in  pyosalpinx,  but 
occasionally  the  abdominal  ostium  does  not  become  sealed,  and  leakage 
of  the  tubal  contents  may  escape  intO'  the  peritoneal  cavity.  This  in 
turn  occasions  recurrent  attacks  of  pelvic  peritonitis,  which  is  relatively 
common  in  all  chronic  tubal  inflammations,  for  it  seldom  happens  that 
both  ostia  are  completely  closed,  especially  in  the  early  stages.  Clini- 
cally, we  are  apt  to  find  one  tube  with  its  ostium  completely  closed,  while 
the  other  is  adherent  by  its  fimbriae  to  some  adjacent  viscus,  a  situation 
which  allows  the  escape  of  its  infected  contents  under  certain  favorable 
conditions. 

Gonorrheal  salpingitis  is  seldom  dangerous  to  life,  for  there  is  a  defi- 
nite tendency  for  the  inflammatory  reaction  to  be  confined  to  areas  within 
the  true  pelvis.  On  the  other  hand,  streptococcic  salpingitis  has  a  defi- 
nite primary  mortality,  and,  owing  to  its  longevity,  greater  virulence, 
and  stronger  tendency  to  extend  beyond  the  confines  of  the  true  pelvis, 
one  can  never  tell  when  a  streptococcic  infection  will  relight  and  prove 
fatal. 

Rupture  of  a  pyosalpinx  may  take  place  into  the  peritoneal  cavity, 
producing  a  fatal  spreading  peritonitis,  or  it  may  rupture  into  and  be 
walled  off  in  the  citl  de  sac  of  Douglas,  where  it  causes  an  active  reaction, 
which  may  be  entirely  confined  within  the  pelvis  and  result  in  a  pelvic 
abscess.  In  rupture  into  the  peritoneal  cavity  with  ascending  peritonitis, 
sudden  severe  abdominal  pain,  high  temperature,  and  a  high  leukocyte 
count,  with  a  polymorphonuclear  percentage  of  over  ninety,  are  evi- 
dences of  the  virulence  and  severity  of  the  extension ;  or  it  may  rupture 
into  the  bladder  and  discharge  its  contents  through  that  organ  as  a 
pyuria,  or  into  the  rectum  or  vagina,  or  even  become  adherent  to  the 
parietal  peritoneum  and  extend  through  the  abdominal  wall  or  point  in 
the  region  of  the  inguinal  canal.  These  ruptures  into  adjacent  viscera 
almost  invariably  result  in  the  formation  of  permanent  fistulae;  conse- 
quently the  relief  caused  by  the  evacuation  of  the  purulent  contents  is 
only  temporary,  mixed  infection  occurs,  and  a  reaccumulation  follows. 
These  pus  sacs  may  intermittently  empty  themselves  through  the  fistula 
during  the  life  of  the  patient.  Such  patients  become  chronically  septic 
and  consequently  are  poor  subjects  for  radical  operations.  Owing  to  the 
inflammatory  reactions  excited  in  the  peritoneal  covering  of  the  intes- 
tines  and  parietal  peritoneum,   intestinal   obstruction   may   complicate 


148  PELVIC  INFLAMMATION  IN  WOMEN 

these  old  cases  of  tubal  inflammation.  When  once  the  intestine  has  be- 
come adherent  to  the  tubal  mass,  the  patient  becomes  a  constant  sufferer 
from  intestinal  disturbances,  which  may  vary  from  simple  gaseous 
distention  to  complete  obstruction. 

The  pus  of  a  gonorrheal  or  of  a  pyogenic  organism,  confined  in  the 
tube,  may  become  sterile  in  from  six  to  eight  weeks,  or  may  continue 
to  be  infective  for  a  longer  time,  but  rarely  if  ever  for  longer  than  three 
months. 

As  we  have  already  stated,  the  two  principal  infective  agents  in  tubal 
inflammations  are  the  gonococcus  and  streptococcus.  These  organisms 
differ  widely  in  the  persistence  of  their  virulence,  but  may  usually  be 
differentiated  clinically,  by  the  history  of  the  infection  and  the  location  of 
the  resulting  lesions. 

Gonorrheal  infection  commonly  extends  along  the  uterine  mucosa 
to  the  tube,  thence  to  the  ovary  and  peritoneal  cavity.  Therefore,  the 
characteristic  lesion  which  we  have  found  has  been  a  suppurative  salpin- 
gitis, a  pyosalpinx  or  hydrosalpinx,  with  or  without  a  complicating 
ovaritis  and  peritonitis,  as  the  results  of  these  inflammations. 

Time  effects  many  symptomatic  cures  in  gonorrheal  infection  of  the 
tubes,  for  we  have  seen  many  pelvic  masses  disappear,  uteri  become 
movable,  and  the  adnexae  insensitive.  The  tube  may,  under  proper  man- 
agement, regenerate  sufficiently  to  allow  the  passage  of  the  ovum.  A  re- 
corded number  of  intra-uterine  pregnancies,  and  numberless  ectopics, 
are  evidence  of  this  complete  or  partial  regeneration. 

Streptococcic  exudates  follow  infections  due  to  miscarriage,  labor 
or  intra-uterine  instrumentation.  The  streptococcic  lesion  is  almost  in- 
variably in  the  parametrium.  From  the  port  of  entry  such  an  infection 
passes  through  the  parametrial  cellular  tissues  by  way  of  the  lymphatics, 
and  by  contiguity  of  tissue  to  the  peritoneum  of  the  tube.  When  infection 
passes  through  these  structures,  it  always  causes  a  more  or  less  sharp 
reaction,  which  produces  an  exudate,  and  hence  we  may  state  that  in 
streptococcic,  tubal  infection  there  is  always  an  associated  parametritis. 

This  chronic  parametrial  mass  is  in  the  broad  ligament,  located  low 
down  beside  the  cervix,  and  blends  with  the  uterine  wall,  making  the 
lower  part  of  the  uterus  appear  broader  and  more  fixed.  In  considering 
the  operative  prognosis  and  management  of  these  streptococcic  tubal  in- 
fections complicated  by  parametrial  exudate,  it  must  be  remembered  that 
the  streptococcus  may  lie  dormant  for  even  ten  or  fifteen  years,  and 
then  light  up  after  surgical  intervention  and  produce  a  fatal  sepsis. 

We  have  had  four  such  cases,  where  the  streptococcus  lay  buried 
in  a  parametrial  exudate  (according  to  the  history)  for  five,  eight,  ten 


SALPINGITIS  149 

and  fifteen  years  respectively,  and  was  liberated  into  the  circulation;  in 
one  by  a  spontaneous  labor,  in  another  by  a  curettage  for  hemorrhage, 
and  in  two  by  a  simple  abdominal  section  for  chronic  tubal  inflammation. 
All  four  cases  subsequently  died  of  a  streptococcic  bacteriemia. 

In  the  author's  study  of  the  cause  of  sterility,  he  was  amazed  to  find 
the  large  number  of  women  who  were  sterile  because  of  chronic  tubal 
inflammation,  which  is  not  appreciable  even  to  the  expert  on  bimanual 
examination.  It  has  been  our  rule  for  several  years  never  to  treat  a  case 
of  sterility  without  having  the  condition  of  the  male  member  of  the 
partnership  checked  up  by.  a  competent  urologist,  not  only  as  to  his  po- 
tency but  as  to  his  previous  or  present  infections.  This  study  has  shown 
that  a  large  number  of  men  marry  who  are  potentially  infective;  that  is, 
who  have  infective  pyogenic  cocci  in  their  prostatic  secretions,  even  when 
no  true  gonococci  can  be  found.  Furthermore,  diplococci  of  an  extra- 
cellular type  and  staphylococci  have  frequently  been  demonstrated. 

From  these  facts,  we  believe  that  a  man  who  marries  with  staphylo- 
cocci in  his  prostate  can  and  does  infect  his  wife  by  setting  up  an  infec- 
tive endocervicitis,  which  of  itself  does  no  harm  except  to  produce  a 
constant  mucopurulent  discharge.  If  we  dilate  such  a  cervix,  or  curet 
the  uterus,  the  cervical  infection  is  passed  on  into  the  uterus  and  tubal 
inflammation  follows.  Clinically,  we  have  proven  the  truth  of  this 
statement  in  over  two  hundred  abdominal  sections  done  for  sterility. 
These  tubes  always  present  the  same  picture,  i.e.,  they  are  distorted  and 
nodulated,  with  thin  peritubal  adhesions.  Sterility  and  chronic  invalid- 
ism are  often  the  results  of  tubal  inflammation. 

In  tuberculous  infection  of  the  tubes  the  process  may  extend  to  the 
peritoneum,  with  a  resulting  pelvic  peritonitis,  or  may  become  gener- 
alized. Spontaneous  recovery  is  possible,  as  in  other  forms  of  tubercu- 
losis. 

The  writer  has  seen  inoperable  tuberculous  salpingitis  become  quies- 
cent, and  remain  so  for  many  years,  only  to  relight  when  the  patient's 
resistance  was  lowered  by  some  other  intercurrent  disease. 

The  operative  prognosis  in  septic  and  gonorrheal  cases  of  tubal  in- 
flammation, when  the  operation  is  done  after  all  of  the  acute  symptoms 
have  subsided,  is  good,  and  if  the  proper  preoperative  care  is  given  to 
these  women,  the  mortality  should  not  exceed  one  per  cent. 

Treatment. — The  treatment  of  salpingitis  must  be  considered  under 
the  following  headings : 

1.  Acute  salpingitis. 

2.  Acute  exacerbations  of  chronic  salpingitis. 

3.  Chronic  salpingitis,  palliative,  conserv'ative,  radical. 


150 


PELVIC  INFLAMMATION  IN  WOMEN 


Treatment  of  Acute  Salpingitis. — No  case  of  acute  salpingitis 
needs  operation.  The  management  during  the  acute  stage  consists  of 
rest  in  bed,  with  the  patient  in  the  Fowler  position,  to  favor  postural 
drainage,  and  the  employment  of  hot  or  cold  applications  over  the  lower 
abdomen.  We  have  found  that  a  hot  antiphlogistine  poultice  spread  on 
cotton  batting  and  applied  over  both  lower  quadrants,  with  a  hot  water 
bag  placed  over  the  poultice  to  maintain  the  heat,  and  both  the  poultice 
and  the  bag  held  in  position  with  a  snug  many  tailed  binder,  serves  the 

purpose  of  supplying 
heat  and  moisture  to  the 
parts,  and  relieves  the 
pain  of  inflammatory  re-, 
action. 

Other  patients  find 
that  cold  is  more  agree- 
able and  has  a  better 
anesthetic  effect  than 
heat.  If  this  is  found  to 
be  the  case,  an  ice  bag 
or  an  ice  coil  may  be  ap- 
plied over  the  affected 
side  or  across  the  entire 
lower  abdomen. 

Salpingitis  tends  to 
spread  by  extension  to 
the  peritoneum,  and 
peritonitis  is  spread  by 
peristalsis;  hence  we 
have  learned  that  postural  drainage,  which  is  accomplished  by  the  use 
of  the  Fowler  elevated  trunk  posture,  tends  to  control  the  upward  ex- 
tension of  the  infection  and  to  keep  the  inflammatory  reaction  within 
the  true  pelvis,  by  allowing  the  sigmoid  and  omentum  to  close  off  the 
pelvic  viscera  from  the  general  peritoneal  cavity  (Fig.  49).  No  cathartic 
should  be  used.  Enemata  may  be  employed  to  empty  the  lower  bowel, 
but  these  should  not  be  larger  than  eight  to  sixteen  ounces,  as  it  is 
desirable  to  limit  their  effect  to  the  terminal  portion  of  the  large  bowel 
and  not  excite  intestinal  peristalsis. 

The  pain  may  l^e  controlled  with  some  form  of  opium.  It  is  well 
to  administer  this  in  small  and  repeated  doses,  as  it  takes  less  anodvne 
to  control  pain  when  a  small  dose  of  the  drug  is  repeated  at  definite 
intervals  than  when  a  larger  dose  is  given,  only  when  the  patient  is 


Fig.  49. — Drawing  from  Operation  Showing  How 
Si(;moid  and  Omentum  Close  off  the  General 
Peritoneal  Cavity  in   Pelvic   Inflammation. 


SALPINGITIS 


151 


suffering  severely.  Besides  relieving  pain,  opium  and  its  derivatives 
diminish  the  intestinal  peristalsis  and  so  tend  to  prevent  the  upward  ex- 
tension of  the  associated  peritonitis. 

Time  does  much  toward  allowing  the  pelvic  organs  to  reassume  their 
normal  functions.  ''Watchful  waiting"  is,  therefore,  the  slogan  in  acute 
salpingitis. 


Fig.  so. — Technic  of  Posterior  Vaginal  Section,  Showing  Point  of  Inosion. 

After  all  temperature  has  subsided  and  the  local  symptoms  have 
become  subacute,  hot  vaginal  douches  of  120°  F.  may  be  given  twice 
daily.  These  douches  do  not  need  to  contain  any  medicant,  but  should 
be  of  such  quantity  that  it  takes  from  fifteen  to  twenty  minutes  to  admin- 
ister, i.e.,  four  to  eight  quarts.  The  douche  should  be  given  with  the 
reservoir  at  low  elevation.  This  supplies  prolonged  heat  without  pro- 
ducing trauma. 

Counterirritation  to  the  vaginal  vault  by  the  application  of  the  tmc- 
ture  of  iodin  or,  as  suggested  by  111,  the  employment  of  cantharides  in 
collodion,  applied  to  the  posterior  fornix  over  the  exudate,  may  aid  reso- 


152  PELVIC  INFLAMMATION  IN  WOMEN 

lution.  When  the  exudate  is  large,  dry  heat,  such  as  can  be  supplied  with 
the  Robinson  "thermolite"  lamp  or  the  Gellhorn  baker,  hastens  the  ab- 
sorption of  the  mass. 

It  will  be  seen,  therefore,  that  the  fundamentals  in  the  treatment  of 
a^ute  salpingitis  are  rest,  posture,  opium,  inhibition  of  peristalsis  (intes- 
tinal rest),  and  time. 


Fig.  51. — Technic  of  Posterior  Vaginal  Section:   ALaking  the  Incision  Through 

THE  Vaginal  Mucosa. 

Under  this  general  plan  of  treatment,  more  or  less  complete  resolu- 
tion takes  place.  Unfortunately,  in  a  few  cases,  instead  of  the  protec- 
tive exudate  being  absorbed,  an  abscess  forms  in  the  eul  de  sac  of  Doug- 
las. When  this  occurs,  the  acute  peritoneal  symptoms  subside,  the  tem- 
perature becomes  remittent  or  intermittent,  the  polymorphonuclear  per- 
centage falls,  and  the  patient  usually  complains  of  pressure  symptoms  in 
the  pelvis,  as  evidenced  by  rectal  and  vesical  tenesmus. 

The  vaginal  findings  show  a  bulging  and  soft  spot  in  the  posterior 
fornix,  while  the  uterus  is  displaced  upward  behind  the  pubis.     When 


SALPINGITIS 


153 


the  diagnosis  of  pelvic  abscess  is  made,  its  contents  may  be  evacuated  by 
posterior  vaginal  section. 

Vaginal  section  is  also  of  value  in  acute  spreading  peritonitis  of  pelvic 
origin  due  to  abortion  or  tubal  leakage.  Our  index  for  surgical  inter- 
ference in  these  cases  has  been  the  occurrence  of  sudden  abdominal  pain, 
which  is  not  relieved  by  the  moderate  use  of  morphin,  abdominal  tension, 


Fig.  52. — The  Scissors  Are  Then  Discarded  and  the  Finger  is  Introduced 

THROUGH    THE    InCISION    IN    THE    VagINAL     MuCOSA. 


tenderness,  high  temperature,  a  high  leukocyte  count,  and  a  polymor- 
phonuclear percentage  of  over  ninety.  Furthermore,  posterior  colpotomy 
and  drainage  is  valuable  as  a  palliative  measure  in  the  treatment  of  pus 
tubes  and  infected  ovarian  cysts  w^hich  are  located  in  the  true  pelvis, 
when  such  a  patient  shows  signs  of  septic  intoxication,  as  evidenced  by 
persistent  temperature  above  101°  F.,  a  leukocyte  count  of  between 
15,000  and  22,000,  with  a  polymorphonuclear  percentage  of  eighty-five 
or  above.  Such  patients  improve  rapidly  when  the  septic  focus  is  evacu- 
ated.   At  a  later  time  radical  operation  may  be  safely  done. 


154 


PELVIC  INFLAMMATION  IN  WOMEN 


The  Tcchnic  of  Vaginal  Section  (posterior  colpotomy)  for  the  cut 
de  sac  drainage  of  pelvic  abscesses,  acute  spreading  peritonitis  of  pelvic 
origin,  large  pus  tubes,  and  infected  ovarian  cysts,  is  as  follows : 

After  properly  cleansing  the  vulva  and  the  vagina,  with  the  patient 
in  the  lithotomy  position,  a  large  operating  vaginal  speculum  is  intro- 
duced, to  retract  the  posterior  vaginal  wall  and  expose  the  cervix  (Fig. 


"^3 

'  JH^"'                                            ^«^^^l 

m 

Jm  111   flk^ 

^^^^^^^V^'                                  VK'    1                                   '-'^^^^^^^K 

f  /•Ifi  ',  |p 

FiG-  53- — Widening  the  Incision  with  the  Fingers. 


50).  The  posterior  lip  of  the  cervix  is  caught  with  two  Skene  double 
tenacula  and  drawn  downward  and  forward.  This  procedure  exposes  the 
posterior  uterovaginal  junction  and  develops  a  depression  or  dimple  be- 
tween the  uterosacral  ligaments  at  their  uterine  attachment  (Fig.  51). 
At  this  point,  with  a  pair  of  long  sharp  pointed  scissors  curved  on  the 
fiat,  a  transverse  incision  is  made  through  the  vaginal  mucosa.  The 
incision  should  1>e  aljout  an  inch  and  a  half  to  two  inches  in  length.  The 
scissors  may  now  be  discarded,  the  speculum  removed,  and  the  finger 


SALPINGITIS  155 

introduced  through  the  incision  in  the  vaginal  mucosa ;  and,  as  the  cervix 
is  drawn  forward,  the  finger  is  kept  close  to  the  posterior  uterine  wall, 
it  is  then  pushed  through  the  cellular  tissue  and  peritoneum  until  the 
cul  de  sac  is  entered  and  the  contained  pus  liberated.  The  index  finger 
of  each  hand  is  now  passed  into  the  incision,  and  the  wound  spread  to 
admit  three  fingers. 


Fig.  54. — Gauze  Rolls   Placed  in  the  Cul  de  Sac  for  Drainage  Are  Preferable 

TO  A  Rubber  Tube. 

The  pelvic  cavity  is  next  explored  for  secondary  pus  pockets  and,  if 
any  are  found,  these  should  be  evacuated.  If  an  infected  cyst  or  large 
pus  tube  presents  itself  in  the  colpotomy  wound,  it  should  be  carefully 
punctured  with  the  scissors  and  the  opening  enlarged  by  the  finger. 
A  long  Sims  speculum  is  now  introduced  into  the  colpotomy  wound,  to 
hold  back  the  posterior  vaginal  wall,  while  a  Deaver  retractor,  placed 
anteriorly  in  the  incision,  holds  the  uterus  forward.  With  these  retrac- 
tors properly  placed,  the  cyst  or  tube  cavity  may  be  exposed  and  a 


156  PELVIC  INFLAMMATION  IN  WOMEN 

T-shaped  rubber  tube  of  large  caliber  placed  in  the  cyst  for  drainage, 
while  the  cul  de  sac  is  filled  with  twisted,  washed  out  iodoform  gauze 
drains,  two  by  twelve  inches,  arranged  across  the  pelvis  (Fig.  54).  We 
usually  place  five  of  these  twisted  drains  in  the  pelvis  and  leave  them 
in  place  for  eight  to  ten  days,  removing  the  middle  one  first.  This 
insures  a  large  patent  opening  in  the  cul  de  sac  that  will  not  become  oc- 
cluded before  the  cavity  above  has  closed  down. 

It  must  be  remembered  that  drainage  depends  on  the  size  of  the  itp- 
cision  through  zvhich  the  drains  emerge,  hence  the  necessity  of  a  large 
opening  in  the  vaginal  vault.  By  following  this  technic,  we  have  never 
had  to  repeat  our  drainage  procedure.  Irrigation  of  the  abscess  cavity 
is  never  used,  for  the  dangers  of  trauma  and  of  the  dissemination  of 
infective  material  beyond  the  pelvis  counterbalance  any  theoretical  ad- 
vantage. The  elevated  trunk  posture  secures  proper  gravity  drainage, 
and  after  the  drains  are  removed,  the  patient  is  instructed  to  lie  upon 
her  abdomen  for  several  hours  daily,  to  ensure  emptying  the  vagina. 

Operative  interz'ention  by  the  abdominal  route  is  generally  contra- 
indicated  during  the  early  stage  of  any  acute  inflammation;  first,  because 
the  patient  may  recover  under  palliative  treatment;  second,  because  col- 
lections of  pus  in  the  pelvis  become  less  virulent  or  sterile,  if  sufficient 
time  is  allowed  for  the  process  to  become  quiescent.  Diffuse  spreading 
peritonitis  is  the  exception  to  this  rule,  and,  when  present,  free  drainage 
through  a  stab  wound  incision  is  demanded. 

Occasionally,  in  these  acute  pelvic  inflammations,  abdominal  dis- 
tention, tympany,  and  vomiting  become  prominent  factors.  Starvation 
and  lavage  will  control  the  vomiting  and  the  distention  in  the  upper  in- 
testinal tract,  while  proctoclysis,  after  the  method  described  by  Harris, 
will  furnish  the  necessary  fluids  for  the  patient,  and  promote  the  escape 
of  gas  from  the  large  bowel. 

The  Harris  drip  is  constructed  from  an  ordinary  tin  or  agate  douche 
can  with  three  to  four  feet  of  soft  rubber  tubing,  to  the  distal  end  of 
which  an  ordinary  rectal  tube  is  attached.  The  can  is  placed  at  an  eleva- 
tion which  exactly  corresponds  to  the  height  of  the  pubis  of  the  patient. 
After  being  half  filled  with  a  five  per  cent  glucose  solution,  at  a  tempera- 
ture of  105°  F.,  a  small  quantity  of  the  fluid  is  allowed  to  escape  through 
the  rectal  tube,  and,  while  it  is  still  running,  the  tube  is  inserted  into 
the  anus;  the  fluid  promptly  seeks  its  level,  and  the  solution  in  the 
bowel  will  be  at  the  same  height  as  the  solution  in  the  agate  reservoir. 
By  keeping  this  constant  column  of  fluid  in  the  rectum  and  sigmoid 
under  low  pressure,  large  quantities  are  absorbed  by  the  colon  and 
little  or  no  irritation  is  produced  by  the  contained  fluid.     Both  feces 


SALPINGITIS  157 

and  gas  are  passed  through,  the  tube  back  into  the  containing  reser- 
voir. The  temperature  of  the  solution  may  be  maintained  by  placing  a 
lighted  incandescent  (carbon)  bulb  in  the  douche  can. 

Before  any  operative  procedure  is  justifiable,  all  acute  symptoms 
must  have  subsided,  and  the  morning  and  evening  temperatures  must 
be  normal  for  a  period  of  at  least  three  weeks,  all  exudate  must  have  been 
absorbed,  or  if  some  still  remains,  it  must  be  hard  and  insensitive.  Pelvic 
examination  will  not,  if  these  conditions  are  fulfilled,  excite  an  exacerba- 
tion of  temperature  or  an  increase  in  the  leukocyte  count.  The  leukocyte 
count  shoidd  never  he  over  eleven  thousand  nor  the  polymorphonuclear 
percentage  over  seventy^Uve  at  the  time  of  making  an  abdominal  section 
for  tubal  inflammatory  disease.  It  is  our  custom  to  test  these  cases  by 
making  a  complete  blood  count  and  then  to  subject  the  patient  to  a  thor- 
ough bimanual  pelvic  examination.  If  this  examination  does  not  free 
any  toxins,  the  temperature  and  leukocyte  count  will  not  be  raised  and 
operation  may  be  safely  done. 

Treatment  of  Chronic  Salpingitis  may  be  palliative,  conserva- 
tive or  radical.  As  we  have  stated  before,  time  effects  a  symptomatic  cure 
in  a  large  number  of  tubal  inflammations.  This  is  especially  true  when 
the  gonococcus  has  been  demonstrated  to  be  the  only  infective  agent 
present.  The  tube  is  often  able  to  recuperate  completely  and  have  the 
patency  of  its  lumen  completely  restored;  therefore  we  feel  that  there 
is  considerable  virtue  in  the  palliative  management  of  these  subacute  and 
chronic  inflammations. 

Palliative. — The  treatment  consists  in  the  maintenance  of  the 
woman's  general  health  by  tonics,  fresh  air,  proper  rest,  and  marital 
continence.  The  regulation  of  the  intestinal  tract  should  be  accomplished 
by  the  use  of  systematic  abdominal  exercise,  proper  diet,  and  the  ad- 
ministration of  mineral  oil  and  enemata.  When  cathartics  are  used, 
only  those  which  exert  their  action  on  the  rectum  and  lower  sigmoid 
should  be  employed.  On  general  principles,  it  is  better  to  avoid  the  use 
of  cathartics  entirely. 

The  associated  cervicitis,  endocervicitis,  and  posterior  parametritis 
which  causes  the  leukorrhea,  the  backache,  the  dyspareunia,  and  the  pre- 
menstrual pain,  may  be  relieved  by  proper  local  treatment.  This  con- 
sists (i)  in  marital  abstinence;  and  (2)  in  the  absorption  of  the  cellular 
exudate  in  the  surrounding  ligaments. 

In  the  first  instance,  we  may  or  may  not  succeed,  depending  entirely 
upon  the  proclivities  of  the  contracting  parties.  To  accomplish  the 
second  result,  hot  vaginal  .douches  with  two  or  four  quarts  of  water 
at  a  temperature  of  120°  F.,  taken  before  retiring,  with  the  patient  in 


158  PELVIC  INFLAMMATION  IN  WOMEN 

the  recumbent  posture  and  the  bag  at  low  elevation,  tends  to  change  the 
pelvic  circulation  and  relieve  the  circulatory  stasis,  and  thus  improve 
the  pelvic  soreness. 

With  the  patient  in  the  knee-chest  position,  counter  irritation  of  the 
fornices  and  local  disinfection  of  the  cervical  area  by  an  application 
of  strong  Churchill's  tincture  of  iodin  over  the  cervix,  cervical  canal, 
and  vaginal  fornices,  tends  to  relieve  the  local  pain. 

In  the  author's  experience,  it  has  not  been  necessary  in  these  chronic 
cases  to  use  more  active  counter  irritants,  such  as  cantharides  collodion. 
Better  results  have  been  obtained  by  the  systematic  employment  of  the 
"Gellhorn  baker,"  applying  the  dry  heat  over  the  lower  abdomen  at  a 
temp  rature  varying  from  140°  to  250°  F. 

Conscientious  persistence  in  maintaining  the  patient's  general  health, 
regulation  of  the  bowels,  douches,  iodin,  heat  and,  above  all,  time  have 
relieved  many  of  these  patients  of  all  of  their  subjective  symptoms. 

It  is  most  important  that  the  patient  who  is  the  subject  of  chronic 
pelvic  inflammation  learn  to  properly  care  for  herself  just  prior  to  each 
menstrual  period,  as  it  is  at  this  time  that  exacerbations  are  most  likely 
to  occur.  These  women  should  be  instructed  to  rest  in  bed  previous  to 
and  during  the  period,  to  abstain  from  meat  for  four  or  five  days  before 
the  onset  of  the  bleeding,  and  finally  to  be  sure  that  the  lower  bowel  is 
emptied  by  an  enema  six  to  twelve  hours  before  the  menstruation  begins. 

The  Operative  Treatment  of  Chronic  Salpingitis  includes  (i) 
salpingostomy,  or  the  partial  resection  of  one  or  both  tubes,  and  (2) 
salpingectomy,  or  ablation  of  one  or  both  tulles  with  a  retention  of  the 
uterus  and  one  or  both  ovaries,  or  part  of  the  uterus,  with  one  or  both 
ovaries  to  maintain  the  menstrual  function. 

Salpingostomy  has  a  limited  field.  This  operation  is  only  permissible 
in  young  women,  in  an  occluded  tube  with  its  free  portion  and  ampulla 
distended,  but  without  persistent  active  inflammation;  as,  for  instance, 
in  certain  cases  of  terminated  hydrosalpinx  which  intermittently  dis- 
charge their  contents  through  the  uterine  cavity,  and  in  tubal  pregnancy 
operated  upon  before  rupture.  In  other  words,  salpingostomy  may  be 
done  where  it  can  be  demonstrated  that  the  interstitial  portion  of  the 
tube  is  patent.  It  is  never  permissible  in  a  gonorrheal  or  tubercular 
infection,  even  where  there  is  no  pus,  as  the  tulle's  subsequent  behavior 
has  demonstrated  that  conservative  surgery  has  no  value. 

Pregnancies  have  occurred  where  this  conservative  procedure  has 
been  done,  but  the  ultimate  termination  is  always  questionable,  as  we 
have  no  means  of  knowing  whether  or  not  any  bacteria  persist  in  the 
tube  walls.     We  have  reported  the  case  of  one  woman  who  has  had 


SALPINGITIS  159 

three  children  subsequent  to  a  phimosis  operation  on  the  tubes,  as  well 
as  three  cases  of  intra-uterine  pregnancy  in  which  the  terminal  portions 
of  both  tubes  were  resected.  In  addition  to  this,  we  have  records  of 
seven  ectopic  pregnancies  occurring  in  the  proximal  portion  of  resected 
tubes. 

Notwithstanding  the  many  recorded  failures  in  the  hands  of  reliable 
operators,  there  are  those  who  still  believe  in  this  form  of  conservatism. 
However,  we  are  convinced  that,  due  to  the  pathological  findings  in  prac- 
tically all  of  these  pelvic  infections,  whether  of  gonorrheal  or  strepto- 
coccic origin,  it  is  very  doubtful  whether  conservatism  accomplishes 
sufficient  in  the  end  to  compensate  for  the  risk  that  accompanies  it. 
After  all,  conservatism  may  eventually  become  radicalism. 

If  a  woman  is  chronically  invalided  by  the  retention  of  an  infected 
tube  or  tubes  following  conservative  salpingostomy,  what  chances  has 
she  of  becoming  pregnant,  and  if  conception  takes  place,  what  chances 
has  she  of  carrying  to  term?  Furthermore,  in  case  no  conception  fol- 
lows, but  the  symptoms  for  which  she  originally  suffered  are  constant 
and  unabating,  what  state  will  her  mental  attitude  assume  when  a  second 
operation  is  advised  as  her  only  alternative  for  health  ?  Such  questions 
cannot  be  answered  with  any  degree  of  certainty.  However,  it  may  be 
assumed  with  certainty,  that  a  woman  who  is  healthy  and  free  of  symp- 
toms (pain,  leukorrhea,  etc.)  and  who  menstruates  regularly,  which  to 
her  always  means  a  possibility  of  conception,  is  far  happier  and  con- 
tented than  one  who  has  symptoms  and  menstruates  irregularly  and 
finally  becomes  convinced  that  she  cannot  become  pregnant  because  she 
is  sick.  Expectation  may  therefore  produce  happiness  or  misery,  depend- 
ing upon  the  physical  and  mental  state  of  the  expectant. 

Technic  of  the  Procedure. — With  the  patient  properly  prepared  and 
in  the  Trendelenburg  posture,  through  a  free  abdominal  incision  the  tube 
is  freed  from  its  parietal  and  visceral  adhesions,  and  it  is  brought  up 
into  the  abdominal  wound,  after  isolating  and  inspecting  the  adjacent 
ovary.  The  peritoneum  is  now  carefully  walled  off  with  wet  gauze 
laparotomy  sponges  and  the  tubal  tumor  incised  along  its  dorsum.  This 
allows  the  escape  of  the  contained  fluid  and  permits  inspection  of  the 
lining  membrane.  A  fine  ear  probe  or  a  number  one  filiform  bougie  may 
now  be  passed  through  the  isthmic  and  interstitial  portions  of  the  tube 
into  the  uterus.  If  the  lumen  is  patent,  this  can  be  replaced  by  a  single 
strand  of  "00"  chromicized  catgut.  When  the  patency  is  thus  assured, 
we  evert  the  mucosa  around  the  trumpet-like  end  by  suturing  it  with  very 
fine  catgut  to  the  peritubal  peritoneum.  In  this  way  we  have  a  large 
funnel  shaped  opening,  without  raw  edges,  for  the  receipt  of  the  ovum. 


i6o 


PELVIC  INFLAMMATION  IN  WOMEN 


If  sufficient  care  is  taken  in  this  eversion  and  all  raw  surfaces  are  com- 
pletely covered,  some  success  may  be  looked  for.  To  increase  the  chance 
of  pregnancy,  the  ovary  should  be  fastened  near  the  open  end  of  the  tube, 
great  care  being  taken  to  avoid  passing  any  suture  through  the  pro- 
tective tunic. 

Partial  resection  of  the  tubes  has  little  or  no  clinical  value  as  a  con- 
setvative  operation,  except  to  allow  an  opportunity  for  the  arrest  in 
transit  of  the  fecundated  ovum.  Tweedy  and  his  assistant  have  each 
recently  reported  cases  of  ectopic  pregnancy  occurring  in  resected  tubes. 
Two  of  our  interstitial  pregnancies  have  occurred  in  the  stumps  of  tubes 
which  had  been  previously  resected  and  ligated.  It  must  always  be  re- 
membered that  the  spermatozoon  can  pass  through  a  smaller  lumen  than 


Fig.  55. — Serial  Sections  Were  Taken  from  Areas  Marked  i,  2  and  3. 

the  ovum,  hence  the  danger  of  ectopic  pregnancy  in  these  attempts  at 
conservatism. 

Complete  ablation  of  the  tube  is  the  common  procedure  in  chronic 
tubal  inflammations  which  demand  operation.  To  our  mind,  if  the 
infective  process  is  one  of  long  standing,  the  uterine  tissue  about  the 
interstitial  portion  of  the  tube  is  always  involved  to  a  greater  or  less 
degree.  We  have  shown  by  serial  sections  through  this  region  that  in- 
flammatory tissue  is  found  at  a  considerable  distance  from  the  in- 
fected focus,  and  that  unless  this  tissue  is  widely  removed  the  woman 
carries  with  her,  through  life,  an  infected  hyperplastic  uterus. 

Furthermore,  in  this  same  class  of  cases,  the  cervix  should  also  be 
removed,  for,  like  the  fundal  area,  it  also  is  a  constant  source  of  infection. 
(The  reader  is  referred  to  the  chapter  on  Endocervicitis,  that  he  may 
appreciate  the  significance  of  this  statement.) 

Leukorrhea  would  l^e  cured  by  this  procedure,  while,  if  the  cervix 
were  not  removed,  leukorrhea  would  persist. 


SALPINGITIS 


i6i 


Technic  of  Salpingectomy. — With  the  abdomen  open  and  the  pelvis 
exposed  and  walled  off  by  placing  a  moist  gauze  laparectomy  pad  across 
the  brim,  the  tubes  are  freed  from  adhesions,  the  ovaries  isolated  and 
inspected,  and  the  tubes  brought  up  into  the  operative  field  by  traction 
with  a  rubber  covered  ring  forceps.  Beginning  at  the  distal  end,  the 
vessels  of  the  mesosalpinx  are  isolated  and  tied  separately  and  the  tube 


vi!::.. 

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Fig.  s6. — Cell   Reaction  in   Tubal  Section  from  Area  3  Showing  Small  Round 

Mucosa. 


cut  free  of  its  mesosalpinx  (Fig.  59)  as  we  go  along.  When  the  cornu 
of  the  uterus  is  reached,  the  two  sheets  of  the  broad  ligament  are  sepa- 
rated with  Mayo  scissors  and  the  fundal  branch  of  the  uterus,  after  it 
leaves  the  utero-ovarian  anastomosis,  isolated  and  tied.  This  allows 
us  to  cone  out  and  remove  the  interstitial  portion  of  the  tube  without 
bleeding,  and  close  the  cornu  with  sutures.  Unless  this  portion  of  the 
tube  is  removed,  a  focal  infection  lurks  in  the  stump  and  a  local  peri- 


l62 


PELVIC  INFLAMMATION  IN  WOMEN 


tonitis  at  this  point  follows.  This  favors  omental  and  intestinal  ad- 
hesions and  thus,  by  increasing  the  circulation,  allows  a  persistence  of 
the  uterine  symptoms. 

It  was  formerly  supposed  that  no  fluid  accumulation  could  occur  in 
the  tube  until  both  the  uterine  and  abdominal  ends  were  sealed,  but  on 
making  serial  sections  through  the  isthmic  and  interstitial  portions  of 
the  tul^e  in  a  large  series  of  cases,  we  have  found  that  the  lumen  of  the 
uterine  end  never  closes,  and  that  the  apparent  occlusion  in  the  isthmic 
and  interstitial  portions,  w^hich  allows  tubal  distention,  is  relative  and 


Fig.   57. — Section   from    Area   2   Showing    Reacijon    iViioux   and   Remote   from 
Interstitial   Portion   cf   Tube. 


not  actual.  This  may  be  explained  by  the  fact  that  the  folding,  edema, 
and  consequent  swelling  of  the  mucosa  make  the  actual  lumen  so  tortu- 
ous that  intratubal  pressure  closes  or  practically  closes  the  uterine  end. 
If  one  recalls  for  a  moment  the  anatomy  of  the  interstitial  portion  of 
the  tul>e,  surrounded  as  it  is  with  an  inner  circular  muscular  coat,  which 
is  continuous  with  the  circular  muscular  coat  of  the  uterus,  one  must 
recognize  the  fact  that  any  inflammatory  process  of  the  mucosa  must 


SALPINGITIS 


163 


•.'ffinuV''  ■■'„    . 

'  ';!'/j,  «::::s. 


♦fi'V 


VulMi 


excite  an  inflammatory  reaction  in  the  muscular  structures  immediately 
surrounding  the  mucous  tube. 

The  muscular  coat,  when  examined  microscopically,  is  edematous  and 
infiltrated  with  inflammatory  tissue  cells  and  plasma  cells,  and  in  mixed 
infections,  particularly  when  the  streptococcus  is  present,  there  may 
be  found  small,  localized  abscesses 
in  the  surrounding  muscle  tissue. 
This  small,  round,  tissue  cell  in- 
filtration results  in  an  increase 
in  the  connective  tissues  within 
the  uterine  wall  and  thereby  ac- 
tually increases  the  size  of  the 
uterus.  These  metritic  changes 
do  not  subside  after  the  removal 
of  the  distal  portion  of  the  tubes, 
but  may  be  found  as  infiltrated 
or  fibrous  nodules  in  the  cornua, 
at  subsequent  operation  or  at  au- 
topsy. 

A  knowledege  of  the  persist- 
ence of  this  infection  of  the 
uterine  muscle  formerly  tempted 
the  French  operators  to  do  vagi- 
nal hysterectomy  with  double  sal- 
pingo-oophorectomy  for  chronic 
suppurative  tubal  infection  ; 
while,  in  this  country,  many  of 
our  more  conservative  surgeons, 
who  acknowledge  that  a  mixed 
infection  of  the  tube  can  never 
be  wholly  cured  without  ablation 
of  both  tubes,  and  that  the  in- 
tractable leukorrhea  which,  under 
certain  stimuli,  regains  its  infec- 
tive properties,  and  the  increased 
amount  of  menstrual  flow,  which, 
together  with  the  pelvic  pain,  make  up  the  clinical  syndrome,  are  all  due 
to  the  enlargement  and  increased  blood  supply  of  the  metritic  uterus,  and 
because  of  the  persistence  of  these  symptoms  have  advocated  hysterosal- 
pingectomy,  with  the  retention  of  one  or  both  ovaries.  While  we  are 
agreed  that  the   retention  of  an   infected   uterus   is   a   menace   to   the 


-'V. 


Fic,  58. — Section  from  Area  i  Shows  In- 
flammatory Reaction  Remote  from 
Tubal  Entrance. 


Fig.  59. — Freeing  the  Tube  from  its  Mesosalpinx  by  Ligating  the  Individual 
Vessels  and  Not  Interfering  with  the  Ovarian  Circulation. 


Fig.  6o. — Showing  the  Extent  of  the  Wedge  Excised  from  Fundus  and  Body. 


164 


Fig.  6i. — Showing  Lines  of  Incision  in  Making  a  Partial  Resection  of  the 
Uterus    Including    the    "Pars    Interstitialis." 


Fig.  62. —  The  Uterine  Flaps  are  Then   Brought  Together  with  Interrupted 

Sutures. 


165 


1 66 


PELVIC  INFLAMMATION  IN  WOMEN 


woman's  future  health,  our  own  feehng  has  been  that,  when  so  much  care 
is  taken  to  preserve  the  function  of  ovulation,  there  should  be  like  care  in 
preserving  to  the  woman  the  function  of  menstruation,  for  ovulation 
without  menstruation  contributes  little  to  the  patient's  well  being,  and 
furtliermore,  a  study  of  serial  sections  through  the  uterus  between  the 
fundus  and  the  internal  os,  show  few,  if  any,  of  the  pathological  changes 
which  have  been  demonstrated  about  the  pars  interstitialis. 

It  is  only  in  the  cervical  region,  in  Naboth's  glands,  in  the  columnar 


Fig.  63. — The  Wurxi)  is  Then  Pekit>.  nealizeu  i;v  Detaching  the  Bladder  and 
Reflecting  the  Flap  Over  the  Suture  Line — the  Ovaries  are  Suspended  by 
Suturing  Them  ro  Round  Ligaments. 

epithelium  of  the  cervical  canal,  in  the  fundal  region,  and  in  the  struc- 
tures surrounding  the  pars  interstitialis ,  that  there  is  a  persistence  of  the 
inflammatory  changes  which  have  already  been  described. 

Curtis  has  demonstrated  that  the  interior  of  the  uterus  is  capable 
of  ridding  and  does  rid  itself  of  any  trace  of  the  infective  process;  hence, 
it  must  appeal  to  any  one  of  any  considerable  experience  that,  in  a  given 
case  of  chronic  specific  infection,  involving  the  cervix  and  the  tubes,  a 
cure  cannot  be  effected  except  by  the  removal  of  these  foci.  The  endo- 
cervicitis  and  cervicitis  may  be  controlled  by  conical  excision  of  the  in- 
fected portion  of  the  portio  vaginalis,  but  the  results  of  the  tubal  infection 
cannot  be  checked  and  its  sequelae  removed,  without  excision  of  the  pars 
interstitialis  and  the  structures  immediately  surrounding  it.  Conse- 
quently, to  preserve  ovulation  as  well  as  the  menstrual  function  in  young 


Fig.  64. — Showing  the  Interovarian  Circulation. 


Fig.  65. — Conserving   the   Ovarian    Circulation   by    Pushing   the   Utero-Ovarian 
Anastomosis  off  into  the  Folds   of  the  Cross   Ligament. 


167 


1 68 


PELVIC  INFLAMMATION  IN  WOMEN 


women  suffering  from  chronic  endocervical  and  tubal  infection,  it  has 
been  our  custom  to  cure  the  leukorrhea  by  the  radical  excision  of  the 
infected  area  in  the  cervix,  and  follow  this  plastic  procedure  by  the 
ablation  of  both  tubes,  with  the  resection  of  the  infected  fundus  of  the 
uterus,  using  a  modified  Bell-Beuttner  technic.  This  leaves  a  sufficient 
amount  of  healthy  uterine  body,  with  its  contained  mucosa,  to  conserve 
the  menstrual  function  and  one  or  both  ovaries  to  continue  ovulation; 
for  the  ovaries  are  seldom  erossb'  diseased  if  their  tunica  is  intact. 


UTERINE  y^RTEPy 
LIGATED 


Fig.  66.- 


-Uterine  Artery   Ligated — Mesosalpinx  and  Ovarian  Ligament  in  Grasp 
OF  A   Hemostat   Forceps. 


Removal  of  the  tubes  and  resection  of  the  upper  segment  of  the  uterus 
can  be  done  without  interfering  with  the  ovarian  circulation.  Hence, 
the  ovary  may  be  retained  with  a  greater  degree  of  security,  than  if  a 
hysterectomy  is  done  and  the  uterine  end  of  the  anastomosis  cut  off. 
Furthermore,  the  functional  life  of  the  retained  ovary  or  ovaries  is  longer 
if  menstruation  is  conserved  than  if  the  uterus  is  removed.  This,  I  be- 
lieve, is  due  to  the  relief  of  the  periodic  premenstrual  congestion  by  the 
uterine  flow.  The  ovary  is  the  analogue  of  the  testicle,  and  we  feel  that 
considerable  risk  is  justified  for  the  preservation  of  an  ovary  and  its  cir- 


SALPINGITIS 


169 


dilation.  For  it  is  well  known  that  double  oophorectomy,  particularly  in 
a  young-  woman,  may  convert  the  normal  woman  into  a  hopeless  neuras- 
thenic. In  tubal  disease  the  ovary  is  usually  involved  only  because  of 
its  association  with  the  infected  tube.  The  lesion  is  a  peri-ovaritis, 
rather  than  an  ovaritis.  It  is  an  ovary  in  bad  company,  rather  than  a 
diseased  ovary,  and  its  function  can  be  preserved,  provided  its  circulation 
is  not  interfered  zvith. 

Menstruation  exercises  a  therapeutic  effect  on  health,  which  is  not 


Fig.  67, — Uterus   Removed,   Round  Ligaments   Sewn  into  Stump — A   Running 
Suture  is  Being  Passed  Around  the  Hemostat. 


only  psychic,  but  actual,  for  the  whole  system  in  the  female  is  planned 
for  this  periodic  outflow.  The  uterine  mucosa  undergoes  definite  his- 
tologic changes  throughout  a  definite  cycle,  which  culminates  in  the  men- 
strual flow.  These  cyclic  changes  are  subconscious  when  proper  corre- 
lation exists  between  the  several  governing  internal  secretions  of  the 
body;  but  when  this  correlation  is  disturbed  by  cystic  changes  in  the 
ovary,  which  always  result  when  its  circulation  is  interfered  with,  defi- 
nite symptoms  are  produced  in  the  breasts,  the  tonsils,  the  thyroid  gland, 
the  genital  spot  in  the  nasal  mucous  membrane,  and  in  the  circulatory 
and  nervous  systems  of  the  individual.  Consequently,  there  can  be 
no  question  as  to  the  desirability  of  the  conservation  of  the  ovarian  func- 


170 


PELVIC  INFLAMMATION  IN  WOMEN 


tion,  provided  it  is  associated  with  the  periodic  overflow  of  menstrual 
blood.  To  have  this,  the  ovary  and  the  uterus  must  be  comparatively 
healthy.  As  has  been  already  stated,  a  healthy  ovary  or  ovaries  and  a 
portion  of  healthy  uterus  can  be  conserved  by  the  employment  of  the 
fundal  resection. 

Technic. — The  success  of  the  Bell-Beuttner  procedure  depends  on  the 
ligation  of  the  fundal  branch  of  the  uterine  artery,  supplying  the  inter- 
stitial portion  of  the  tube  and  uterine  fundus.     This  is  done,  as  in  sal- 


,. 

j/^S^tlUmk 

.1 

m-  ., 

^fl 

/-',—■ 

K. 

^1 

^J,     1 

&y 

\.\ffjm^-  ^^P 

jr,^^mmm^^y  \\J\"\^"\^   .ymm 

^> 

■ 

m '  \ 

^|(*    *^^*S^*^ 

^ 

.p,g^8Si**r-      jjj.jjii    -s(. 

^fH 

Fig.  68. — Conserved  Ovary  and  Tube  Suspended  by  Suture  to  the  Round  Ligament 
Supported  by  Peritoneal  Pocket — This  Method  is  Applicable  Only  when 
One  Tube  is  Normal. 


pingectomy,  by  separating  the  anterior  and  posterior  sheets  of  the  broad 
ligament  and  exposing  the  vessel  just  after  it  leaves  the  utero-ovarian 
anastomosis.  With  the  bleeding  controlled,  a  wedge  shaped  excision 
is  made  of  the  upper  part  of  the  body  and  fundus  of  the  uterus  (Fig.  6o). 
The  anterior  incision  begins  just  posterior  to  the  insertion  of  the  round 
ligament  and  runs  across  the  front  of  the  uterus  to  a  corresponding 
point  on  the  opposite  side  (Fig.  66).  The  posterior  incision  begins  be- 
tween the  tubal  insertion  and  the  ovarian  ligament  on  one  side,  and  ex- 
tends across  the  posterior  surface  of  the  uterus  to  the  same  point  on 
the  opposite  side.  The  incision  is  wedge  shaped  and  is  made  in  such 
a  manner  that  the  entire  fundal  mucosa,  with  the  pars  interstitialis  and 


SALPINGITIS 


171 


the  surrounding  tissues  of  both  sides,  is  included  in  the  excised  mass 
of  uterine  tissue.  The  uterine  flaps  are  then  brought  together  with  in- 
terrupted catgut  sutures,  superficial  sutures  being  placed  between  the 
deeper  ones.  This  wound  is  then  peritonealized  by  detaching  the  bladder, 
as  is  done  in  panhysterectomy,  and  the  peritoneal  flap  is  reflected  over 
the  line  of  incision;  this  anteverts  the  uterus,  beside  practically  making 


Ligation  of 
ovarian  artery 
and  vein 


amp  on 
■  infundibulo-pelvic  li^. 


H.I.SKanr 


Fig.  69. — The  Uterus  is  Drawn  Out  of  the  Wound  by  a  Large  Jacobs  Forceps. 

the  uterine  incision  extraperitoneal.  These  patients  have  made  smooth 
recoveries  and  have  menstruated  regularly  without  pain,  bladder  disturb- 
ance, or  other  pelvic  symptoms. 

Radical  Treatment. — We  have  seen,  in  the  study  of  the  pathology 
of  chronic  tubal  inflammation,  that  the  uterus  and  ovaries  are  always 
more  or  less  involved  in  the  inflammatory  process,  and  at  times  are  actu- 
ally infected  and  remain  infected,  even  after  the  source  of  the  uterine 
and  peritoneal  infection  has  been  removed.  Hence,  we  may  have  ovaries, 
not  only  in  bad  company,  but  actually  diseased. 


172 


PELVIC  INFLAMMATION  IN  WOMEN 


When  the  ovaries  are  healthy  and  the  tubes  are  removed,  the  circu- 
lation in  the  ovary  is  more  or  less  impaired,  and,  unless  great  care  is 
taken  to  preserve  this  blood  supply,  the  ovary,  which  is  retained  for  its 
supposed  internal  secretion,  becomes  cystic.  If,  on  the  other  hand,  the 
ovary  is  diseased,  conservation  after  removal  of  the  tube  produces  an 
ovarian  pathology  that  frequently  invalids  the  patient. 


^.amp  on  , . 

infundib. pelvic  lig- 


Fig.  70. — A  Clamp  is  Placed  on  the  Infundibulopelvic  and  Round  Ligaments 
AND  THE  Ligaments  Tied  Distal  to  the  Clamp. 

The  uterus,  also,  becomes  enlarged  from  continued  infection.  This 
enlargement  produces  a  menorrhagia  or  metrorrhagia,  which  symptoms 
will  persist  as  long  as  the  infected  organ  is  retained.  Hence,  it  will 
l)e  seen  that  frequently  the  best  interests  of  the  patient  are  conserved 
by  the  complete  removal  of  her  pelvic  organs.  This  radical  extirpation 
removes  those  foci  of  infection  which  are  beyond  nature's  reparative 
powers,  and  so  relieves  the  woman  of  her  constantly  recurring  pelvic  in- 
flammation. 

When  hysterectomy  is  done  for  chronic  pelvic  inflammation,  it  should 
include  the  removal  of  the  cervix,  for  the  retention  of  an  infected  cervix 


SALPINGITIS 


173 


acts  as  a  focus  for  the  continuance  of  parametrial  inflammation;  besides 
this,  the  cervix,  with  its  infected  glandular  structures,  becomes  a  con- 
stant source  of  leukorrhea.  This  cervical  discharge  is  just  as  intract- 
able in  the  cervix,  retained  after  hysterectomy,  as  in  the  cervicitis  con- 
sidered in  a  previous  cliapter.  The  leukorrhea  remains  a  constant 
nuisance  to  the  patient.  Finally,  we  cannot  close  our  eyes  to  the  possi- 
bility of  malignant  degeneration  occurring  in  the  retained  cervix. 

Technic  of  the  Radical  Operation. — When   the  bladder  has  been 


Fig.    71. — The   Ligaments    are   Cut    Between    the   Clamp    and   Ligature. 


emptied,  the  vagina  is  rendered  sterile  by  painting  the  vaginal  walls 
and  cervix  with  tincture  of  iodin,  and  the  vagina  is  then  packed  with 
iodoform  gauze.  The  patient  is  now  placed  in  a  Trendelenburg  posture 
and  anesthetized,  the  anesthetic  being  continued  while  the  skin  prepara- 
tion of  the  abdomen  is  made.  There  is  considerable  advantage  in  having 
the  patient  in  the  high  Trendelenburg  posture  before  the  abdomen  is 
opened,  as  suggested  by  Guthrie,  for,  by  observing  this  detail,  the  in- 
testines tend  to  gravitate  upward  from  the  pelvis,  and  remain  out  of  the 
field  of  operation.  When  the  abdomen  is  opened,  this  diminishes  the 
amount  of  trauma  to  which  the  intestine  is  subjected  and  consequently 
the  surgical  shock. 


Forceps  holding 
suture  on  rd.lig- 


Fig.  72. — A  Curved  Mayo  SassoRS  is  Passed  under  the  Vesical  Reflection  of  the 
Peritoneum   which  is   Cut   Free  of  the  Uterus. 


, 

jM^«\  Forceps  holding  flap 
Hf\\\  of  bladder  rerlection 

Suture  on  rd.lio;       ^fl 

liyi^                _,^gs5 

K^|t%^                      ^00^ 

^^x^^  li^^^l 

m^  (  ^A  -v^bgjiF'tero-vgsicat  M^Mt 

y^"      Mk  ^^^^^k 

W  [  f\  imMm^Uj^^                   ^ 

1^1  ^^^r  " 

ti^^^tm '  ^iHJlAo^^^^^^le^^HV^ 

v^HI^M^/ 

iP^i^^L^ 

l^^^^r^^l 

K/      ^l^"\    ' '  '^■^l 

j^H^lH 

Hi     i^'?^''^! 

^m^\ 

^^^^^^mtfi  '^ '    ■ 

^^^|H|rjHtt^\       ^^B 

"^ITj.^K^^^^BjI^yy    ] 

^^KAl^^^k^^B 

Fig.  73. —  Anterior  Bladder  Reflection   Carried  Over  Vaginal  Vault, 

174 


SALPINGITIS 


175 


The  abdomen  is  opened  by  a  long  incision  in  the  median  line,  or 
just  to  the  right  of  the  median  Hne.  The  incision  should  extend  from  the 
pubis  to  above  the  umbilicus,'  for  a  long  incision  greatly  facilitates  the 
ease  of  operation.  As  soon  as  the  peritoneum  is  opened,  two  fingers  are 
inserted  in  the  lower  end  of  the  abdominal  incision,  elevating  it.  This 
allows  air  to  enter  the  peritoneal  cavity,  and  the  atmospheric  pressure 


Scissors 

spreading 

bd.Jitfamen't 


Ketraclcr  holdincr 


Ovarian  artery 
ligaied 


HJ-SKannorv 


Fig.  74. —  The  Bladder  is   Retracted  axd  Uterine  Artery   Exposed. 

causes  the  intestines  to  further  recede  from  the  field  of  operation.  The 
wound  edges  are  now  protected  by  towels,  and  a  moist  laparotomy  sponge 
is  placed  across  the  pelvic  brim,  so  as  to  protect  the  intestines  from 
trauma  and  infection. 

The  uterine  fundus  is  grasped  by  a  large  Jacob's  forceps  and  the 
uterus  is  drawn  up  out  of  the  wound  and  the  adhesions  of  the  tubes  and 
ovaries  freed,  so  that  the  infundibulopelvic  ligaments  with  their  con- 
tained blood  vessels  are  exposed.  A  Kocher  clamp  is  now  placed  on  the 
infundibulopelvic  ligament  (Fig.  70),  including  the  ovarian  artery  and 


176 


PELVIC  INFLAMMATION  IN  WOMEN 


vein.  Distal  to  this  clamp,  a.  suture  ligature  is  passed  through  the  free 
space  in  the  ligament,  and  the  ovarian  artery  and  vein  tied.  The  liga- 
ment is  now  cut  distal  to  the  clamp  and  the  vessels  retract.  The  round 
ligament  is  next  grasped  with  a  clamp  and  tied,  distal  to  the  clamp,  and 
then  severed  between  clamp  and  ligature  (Fig.  68).  This  allows  the 
folds  of  the  broad  ligament  to  be  separated  and  the  uterine  artery  and 
vein  exposed  and  isolated  as  they  come  up  to  the  side  of  the  uterus.    The 


Fig.  75. — Uterine  Artery  Caught  Between  Two  Clamps  and  Cut. 

same  procedure  is  repeated  on  the  opposite  side  of  the  pelvis.  We  next 
grasp  the  round  ligament  with  a  pair  of  pick-up  forceps,  and  with  a  pair 
of  Mayo  scissors,  curved  on  the  flat,  separate  the  bladder  reflexion  of 
the  peritoneum  from  the  front  of  the  uterus  (Fig.  72).  If  the  proper 
line  of  cleavage  is  found,  which  is  very  superficial,  the  peritoneum  and 
bladder  may  be  separated  without  causing  any  hemorrhage.  This  is 
best  done  by  pushing  the  closed  scissors  along  the  line  of  cleavage  and 
spreading  them  by  opening  the  blades.  In  the  median  line  the  bladder 
ts  firmly  attached  to  the  uterus.    This  attachment  must  be  severed  with 


SALPINGITIS  177 

the  scissors,  as  illustrated  in  the  figure.  After  this  ligament  (Goffe's 
ligament)  is  cut,  the  bladder  is  readily  pushed  off  of  the  front  of  the 
uterus,  vagina,  and  from  the  loose  cellular  tissues  at  the  base  of  the 
broad  ligaments.     With  an  anterior  retractor  holding  the  bladder  for- 


FiG.  76.— The  Uterus  is  Drawn  Forward  and  an  Incision  is  Carried  Across  the 

PosTERiOB  Peritoneal  Fold. 

ward,  and  the  uterus  well  drawn  up  toward  the  opposite  side,  the 
uterine  artery  may  be  easily  isolated  by  blunt  dissection  with  the  Mayo 
scissors.  The  artery  is  now  clamped  in  two  places  and  cut  between  the 
clamps.  Having  repeated  the  procedure  on  the  opposite  side,  the  uterus 
is  drawn  forward  over  the  pubis  and  the  attachments  of  the  uterosacral 
ligaments  exposed.    Just  above  the  point  of  their  attachment  the  posterior 


178 


PELVIC  INFLAMMATION  IN  WOMEN 


sheet  of  the  peritoneum  is  severed.  This  allows  the  uterus  to  be  drawn 
upward,  and  the  ureters  will  naturally  fall  away  from  the  immediate 
field  of  operation.  With  the  bladder  separated  from  the  front  of  the 
vagina  and  held  out  of  harm's  way  with  a  Doderlein  retractor,  a  pair  of 
sharp  pointed  scissors,  curved  on  the  flat,  are  placed  against  the  anterior 
vaginal  wall,  just  below  the  cervicovaginal  junction,  and  forced  through 


Fig. 


•Curved  Scissors  Forced  into  the  V.\gina. 


into  the  vagina.  When  the  vagina  is  entered,  a  Jacob's  forceps  grasps 
all  coats  of  the  anterior  vaginal  wall;  while  the  scissors  enlarge  the 
opening  in  the  vagina,  a  second  Jacob's  forceps  seizes  the  anterior  lip 
of  the  cervix  and  draws  it  up  through  the  vaginal  wound.  The  cervix 
and  upper  end  of  the  vagina  are  now  disinfected  with  tincture  of  iodin, 
and  a  Jacob's  forceps  placed  on  the  posterior  lip  of  the  cervix  (Fig.  78). 
With  the  cervicovaginal  junction  now  in  plain  view,  it  is  an  easy  matter 
to  cut  the  uterus  free  at  this  point  with  the  scissors;  as  the  cervix  is  sev- 


SALPINGITIS 


179 


ered  from  the  vagina,  a  Jacob's  forceps  grasps  the  posterior  vaginal  wall 
at  about  the  midline. 

After  the  uterus  and  its  adnexa  have  been  removed,  the  vagina, 
which  is  drawn  up  by  traction  on  the  Jacob's  forceps,  is  closed  and  the 
cut  edges  approximated  by  two  figure  of  eight  sutures  (Fig.  82).  When 
these  sutures  are  tied,  the  ends  are  left  long  and  they  act  as  traction 
sutures.     We  now  proceed  to  tie  the  uterine  arteries  and  the  vaginal 


J  l£^'  ^^''Ceps  holdmg- 

^jAtH 

1  lai^lap  of  vaginal 

J 

1  IHlijg  incision 

^' 

^^Bl^^^'' 

■ 

Hi 

^^Mj^ 

■ 

1 

i^^ 

A 

iS 

Wk 

*^i 

V    ^^^1 

B 

HH|«m  \  -^ 

% 

''VA 

^■1 

H^#^^' ' 

^^''^ 

Fig.   78. — Scissors    Enlarging   the   Vaginal   Incision    at   the    Cervicovaginal 

Section. 


branches  of  the  uterine,  which  are  in  the  grasp  of  the  hemostats.  This 
completes  the  hemostasis,  and,  if  the  preceding  detail  is  observed,  leaves 
the  surgeon  with  a  perfectly  dry  field  to  peritonealize.  A  suture  is  next 
passed  through  the  muscular  coat  of  the  posterior  vaginal  wall,  through 
the  round  ligament  just  to  the  outer  side  of  the  point  at  which  it  is 
ligated,  and  then  passed  through  the  muscular  coat  of  the  anterior 
vaginal  wall.  When  this  is  drawn  taut,  the  round  ligament  is  sewn  into 
the  vaginal  vault;  the  hgament  of  the  other  side  is  treated  in  a  similar 
manner.    We  are  convinced  of  the  necessity  of  this  detail,  for  too  often 


iSo 


PELVIC  INFLAMMATION  IN  WOMEN 


hysterectomy  is  followed  by  prolapse  of  the  vaginal  walls,  unless  this 
point  of  the  technic  is  observed. 

After  the  round  ligaments  are  securely  sutured  to  the  vaginal  vault 
and  we  are  sure  that  the  hemostasis  is  complete,  we  are  ready  to  begin 
the  peritonealization.    This  is  done  by  suturing  the  posterior  fold  of  the 


Forceps  approachin<; 
;t. cervical  lii 


Forceps  ho 
of  V 


Fig.  79. — The  Cervix  is  then  Drawn  up  thkuugh  the  Vaginal  Incision. 

peritoneum  to  the  anterior,  burying  the  stump  of  the  ovarian  artery 
(Fig.  85),  using  a  running  suture  of  fine  catgut.  When  the  uterosacral 
ligaments  are  reached,  they  are  attached  to  the  muscular  coat  of  the  pos- 
terior vaginal  wall,  and  the  anterior  bladder  reflection  is  carried  over 
the  vaginal  vault  with  the  attached  round  ligaments  and  sutured  to  the 
uterosacrals.  This  gives  the  stump  an  additional  support  and  helps  to 
maintain  it  high  in  the  pelvis.     When  the  peritonealization  is  complete, 


Forceps  ^^o^'ii'^g'^a 
of  vag^ijial  igkoSion  , 


luraied 


Fig.  8o. — Sterilizing   the  Vaginal   Portion  of  the   Cervix. 


Fig,  8i.— Exposing  the  Posterior  Cekvicovaginal  Junction. 

I8l 


Fig.  82. — Closing  the  Vaginal  Vault  with  Figure  of  Eight  Sutures. 


Fig.  83. — Sutures  Tied  and  Used  as  Tractors. 
182 


K" 

/ 

k 

^g«a 

ipSiyiH 

Bl 

^H-' 

J 

n 

M 

B 

1 

1 

ffi 

H 

■ 

1 

mi 

HI 

^^ 

4 

HI 

Fig.  84. — Ligatures  Passed  about  the  Uterine  and  Vaginal  Branch. 


Fig.  85. — Drawing  the  Round  Ligament  into  the  Stump. 

183 


Fig.  86. — Roukd  Ligaments  Sewn  into  the  Vaginal  Stump  and  Peritonealization 

Begun. 


Fig.  87. —  Peritonealizing   the   Raw   Surfaces. 
184 


Fig.  88. — Finished  Operation  When  Ovary  and  Tube  Can  be  Conserved. 


Fig.  89.— The  Compleied  Operation,  when  Both  Ovaries  Have  Been  Removed. 


1^5 


i86  PELX'IC  INFLAMMATION  IN  WOMEN 

the  pelvis  should  present  no  raw  surface  at  any  point,  the  suture  holes 
Ijeing  the  only  possible  point  for  adhesion. 

To  our  mind  the  points  which  give  the  best  success  to  hysterectomy 
are  (i)  the  complete  removal  of  the  cervix;  (2)  complete  hemostasis; 

(3)  suture  of  the  round  and  uterosacral  ligaments  in  the  vaginal  vault; 

(4)  perfect  and  careful  peritonealization  of  all  raw  surfaces  in  the  pelvis. 


CHAPTER  VIII 
OVARITIS 

Mode  of  invasion  and  etiology  in  ovaritis — Pathology — Usually  a  history  of  gonorrheal 
infection — Chronic  ovaritis — Atrophic,  hyperplastic,  and  cystic  forms — Sterility — 
Treatment  of  chronic  ovaritis. 

In  order  to  appreciate  the  pathology  resulting-  from  the  inflamma- 
tory changes  which  take  place  in  the  ovary,  it  may  be  well  to  briefly 
review  the  histologic  structure  of  this  organ.  The  ovary  is  composed 
in  great  part  of  connective  tissue,  which  is  continuous  through  the 
sheaths  of  the  vessels  that  enter  at  the  hilum  with  the  connective  tissue 
between  the  layers  of  the  broad  ligament.  This  continuity  of  tissue 
allows  an  avenue  of  entrance,  through  the  lymphatics  in  the  broad  liga- 
ment, for  infection  from  the  cervix.  Around  the  periphery  of  the  organ 
the  connective  tissue  is  condensed  to  form  a  dense  fibrous  tunic  called 
the  tunica  albuginea,  which,  when  unbroken,  is  protective.  On  the 
surface  of  this  tunic  is  a  single  layer  of  low  cuboidal  epithelium,  which 
is  the  remains  of  the  original  germinal  epithelium  from  which  the  fol- 
licles develop.  Underneath  the  tunica,  in  the  cortical  zone  of  the  ovary, 
lie  the  ova,  each  enclosed  in  its  graafian  follicle.  The  blood  vessels  enter 
the  hilum. 

Oophoritis  or  ovaritis  is  an  inflammation  of  the  tissues  of  the  ovary. 
It  may  appear  in  either  an  acute  or  chronic  form;  each  presents  a  dis- 
tinct pathology  with  terminal  results. 

Mode  of  Invasion  and  Etiology. — Acute  ovaritis  is  produced  by 
an  extension  of  septic  or  gonorrheal  infection  from  the  uterine  tube, 
or  an  extension  of  infection  from  the  broad  ligament  through  the  lymph 
channels  entering  the  hilum.  Septic  ovaritis  is  most  frequently  met  in 
the  puerperium  as  a  direct  invasion  of  the  ovary  by  infection,  after 
labor  or  abortion.  But  bacteria  may  enter  through  the  hilum  from  cel- 
lular or  lymphatic  infections  in  the  broad  ligament,  while  in  the  gonor- 
rheal form,  extension  is  from  the  tube  and  commonly  produces  a  peri- 
oophoritis. Occasionally  it  gains  entrance  to  the  interior  of  the  organ 
by  infecting  the  follicles,  and  causes  an  ovarian  abscess.  Abscess  for- 
mation, however,  is  more  frequently  met  with  in  septic  than  in  gono- 
coccic  ovaritis. 

187 


i88  PELVIC  INFLAMMATION  IN  WOMEN 

Pathogenic  bacteria  may  also  reach  the  ovary,  by  the  hematogenous 
route,  from  infective  foci  in  remote  regions  of  the  body.  This  is  illus- 
trated in  the  ovaritis  complicating  the  exanthemata  and  the  ovaritis 
produced  by  streptococcic  infection  of  the  tonsils  (Rosenau).  Most  of 
the  pyogenic,  as  well  as  a  goodly  number  of  pathogenic  bacteria,  have 
been  demonstrated  in  the  ovary.  Tul^erculous  ovaritis  is  not  infrequent, 
though  it  is  seldom  primary  in  origin,  the  involvement  usually  being 
secondary  to  tuberculous  salpingitis  or  peritonitis. 

Pathology. — In  acute  ovaritis  the  ovary  is  uniformly  swollen,  red- 
dened, and  edematous ;  it  is  sometimes  enlarged  to  several  times  its  nor- 
mal size ;  the  stroma  becomes  infiltrated  with  a  serous  exudate,  and 
small  round  cells  are  deposited  between  the  follicles ;  the  follicular  epi- 
thelium degenerates,  the  ovum  dies  and  is  absorbed,  and  the  liquor 
folliculi  becomes  turbid.  These  exudative  processes  increase  the  intra- 
ovarian  tension  and  explain  the  exquisite  pain  and  sensitiveness  in  the 
ovary  which  are  characteristic  of  acute  ovaritis.  At  the  same  time  a 
lymphatic  exudate  is  poured  out  on  its  surface  which  forms  plastic  adhe- 
sions with  the  adjacent  structures.  The  termination  of  acute  ovarian 
inflammation  must  depend  on  the  virulence  of  the  infecting  organism 
and  the  resistance  of  the  individual  tissues.  A  resolution  will  follow, 
if  the  exudate  becomes  absorbed,  leaving  the  ovary  in  an  apparently 
normal  condition;  on  the  other  hand,  the  activity  of  the  inflammation 
may  subside,  and,  atrophy  of  the  connective  tissue  of  the  stroma  take 
place,  with  a  resulting  sclerosis;  or  again,  suppuration  may  follow, 
leading  to  abscesses  in  the  corpus  luteum  follicles  or  interstitial  spaces, 
with  partial  or  total  destruction  of  the  ovary.  Finally,  the  acute  inflam- 
matory process  may  subside  and  become  subacute  or  chronic,  with  a 
resulting  chronically  contracted  painful  ovary,  or  cystic  degeneration  of 
the  follicular  elements  may  take  place. 

Symptoms  and  Signs. — There  is  tisnally  a  history  of  septic  or 
gonorrheal  infection  of  the  pehnc  organs  or  of  streptococcic  tonsilitis  or 
of  the  exanthemata.  The  patient  complains  of  chills  or  having  chilly 
sensations,  of  intense  agonizing  pain  and  tenderness  in  the  ovarian 
region  (or  in  both  ovarian  regions),  radiating  to  the  back,  down  the 
thigh,  and  to  the  breast.  There  is  frequently  uterine  bleeding  (metror- 
rhagia), occasionally  nausea  and  abdominal  distention.  If  the  attack  is 
near  a  menstrual  period  there  is  severe  dysmenorrhea,  and  bowel  move- 
ments are  attended  with  sickening  pelvic  pain.  Coitus  is  always  pain- 
ful. Abdominal  palpation  will  elicit  tenderness  and  abdominal  tension 
over  the  ovarian  region,  while  vaginal  exploration,  which  is  painful, 
shows  the  ovary  to  be  enlarged,  exquisitely  tender,  and  usually  prolapsed. 


OVARITIS  189 

There  is  nothing  else  in  the  pelvis  so  exquisitely  painful  as  an  inftamcd 
ovary. 

Except  when  the  infection  is  a  complication  of  the  exanthemata  or 
of  tonsillitis,  ovaritis  does  not  occur  as  a  separate  entity,  but  occurs  as 
a  part  of  a  general  pelvic  inflammation  where  the  cellular  and  peri- 
toneal tissues  are  involved ;  and  the  symptoms  and  signs  are  those  of 
acute  infection,  pelvic  peritonitis,  or  tubo-ovarian  inflammation;  hence 
the  physical  signs  mentioned  above  are  not  available  for  making  the 
specific  diagnosis  of  acute  ovaritis,  except  in  isolated  cases. 

Treatment. — As  has  already  been  stated,  except  when  the  infection 
is  a  complication  of  the  exanthemata  or  of  tonsillitis,  ovaritis  does  not 
occur  as  a  separate  entity,  but  occurs  as  a  part  of  a  general  pelvic  in- 
flammation, where  the  cellular  and  peritoneal  tissues  of  the  pelvis  are 
coincidently  involved;  hence,  the  diagnosis  is  always  complicated  by  the 
symptoms  and  signs  of  these  acute  infections.  It  will  be  seen  therefore 
that  the  treatment  in  the  acute  stage  must  necessarily  he  similar  to  that 
of  acute  pelvic  peritonitis  or  salpingitis;  namely,  local  rest  and  the  relief 
of  the  intense  ovarian  pain,  which  is  produced  by  the  increased  intra- 
ovarian  tension,  consequent  upon  the  edema  and  cell  proliferation  which 
occurs  within  the  tense  unyielding  ovarian  capsule.  The  Fowler  position, 
with  the  application  of  heat  or  cold  applied  directly  over  the  ovarian 
region,  and  the  administration  of  morphin,  will  relieve  the  intense  pain 
and  tend  to  localize  the  inflammatory  reaction.  As  the  ovary,  when  it  is 
the  seat  of  an  infective  inflammation,  always  tends  to  drop  into  the  cul 
de  sac,  bowel  movements  are  intensely  painful,  because  of  the  close  prox- 
imity of  the  swollen  painful  ovary;  hence,  the  use  of  cathartics  should 
be  avoided  and  the  lower  bowel  emptied  with  small  non-irritating 
enemata.  In  our  experience,  active  counterirritation,  either  over  the 
ovarian  region  or  applied  to  the  vaginal  vault,  has  not  given  any  relief 
of  the  pain.  Not  until  the  acute  symptoms  produced  by  the  peri- 
oophoritis and  the  associated  peritonitis  have  subsided,  should  any  local 
applications  be  made  to  the  vaginal  vault.  It  will  be  seen,  therefore,  that 
aside  from  the  relief  of  pain,  time  alone  is  the  factor  which  contributes 
to  the  resolution  of  the  actite  ovarian  inflammation. 

After  the  acute  symptoms  are  quiescent,  hot  vaginal  douches  of 
120°  F.  will  hasten  the  absorption  of  the  peri-ovarian  exudate.  If  an 
abscess  forms,  it  will  be  shown  by  the  persistence  of  an  evening  tem- 
perature, increased  size  of  ovary,  and  a  leukocytosis.  Drainage  should 
be  made  by  vaginal  section ;  this  may  be  followed  later  by  oophorectomy, 
when  all  acute  symptoms  have  subsided. 

Chronic  Ovaritis. — Chronic  ovaritis  may  be  the  terminal  stage  of 


igo  PELVIC  INFLAMMATION  IN  WOMEN 

an  acute  infection,  or  may  result  from  any  condition  which  produces  and 
maintains  a  long  continued  congestion  of  the  ovary,  as,  for  example, 
retrodisplacements  of  the  uterus,  subinvolution,  constipation,  masturba- 
tion, sexual  excesses,  etc.  All  of  these  conditions  interfere,  more  or  less, 
with  the  efferent  circulation  and  produce  a  chronic  venous  stasis,  which 
ultimately  results  in  either 

(i)  Atrophic  oophoritis, 

(2)  Hyperplastic  oophoritis,  or 

(3)  Cystic  oophoritis. 

In  the  atrophic  form,  which  is  inflammatory  in  origin,  the  principal 
structure  involved  is  the  stroma,  but  often  the  parenchyma  also  partici- 
pates in  the  local  tissue  changes.  There  is  an  overgrowth  of  connective 
tissue  and  the  follicles  atrophy  from  pressure.  This  form  is  recognized 
by  the  following  characteristic  gross  appearances :  the  ovary  is  of  small 
size,  sclerotic,  having  a  nodular  surface  and  a  thick  tunic;  there  are 
practically  no  follicles. 

The  hyperplastic  form  of  chronic  ovaritis  is  a  result  of  stasis,  and 
hyperplasia  of  the  stroma  results.  It  is  recognized  by  its  increased  size 
and  the  nearly  smooth  white  surface.  On  section  we  find  the  tunic 
immensely  thickened  and  the  stroma  dense,  with  a  few  follicles  in  the 
deeper  structures. 

The  cystic  ovary  is  the  direct  result  of  passive  congestion  and  hyper- 
plasia of  the  stroma;  the  ovary  is  large  and  presents  irregular  groups 
of  cysts  throughout  the  gland,  which  give  the  ovary  an  irregular  shape. 
These  follicular  degenerations  have  been  attributed  by  Rosenau  and 
Davis  to  early  hematogenous  streptococcic  infection.  Clinically,  it  would 
seem  that  the  thick  tunic  and  dense  stroma  prevented  the  natural  matura- 
tion of  the  follicle,  consequently  numberless  immature  follicles  are 
arrested  in  their  progress  toward  the  surface.  The  thickened  tunica 
albuginea  and  the  degeneration  of  the  follicles  explain  the  sterility. 

Symptoms. — There  is  usually  pain  in  one  or  both  ovarian  regions, 
which  is  aggravated  by  standing  or  walking  and  before  and  during  men- 
struation. The  pain  sometimes  extends  to  the  back  and  down  the  thigh 
and  there  is  dyschesia,  especially  if  the  left  ovary  is  prolapsed  and  the 
sigmoid  and  rectum  are  loaded  with  fecal  masses.  Dysmenorrhea  is  a 
constant  symptom  of  chronic  ovarian  disease,  and  pain  precedes  the  ap- 
pearance of  the  flow  and  the  ovarian  soreness  usually  continues  after  the 
flow  has  ceased.  Marital  relations  are  always  painful  and  even  the 
introduction  of  the  douche  nozzle  causes  pain.  With  large  cystic  ovaries 
there  is  not  infrequently  some  anomaly  in  the  menstruation.    This  may 


OVARITIS  191 

take  the  form  of  a  menorrhagia  or  what  is  more  usuai  a  metrorrhagia, 
with  a  more  or  less  continuous  spotting  after  the  normal  flow  has  ceased. 
In  atrophic  ovaritis  there  is  amenorrhea.  Premenstrual  pain  and  enlarge- 
ment of  the  breast,  hysteria  and,  hystero-epilepsy  are  often  associated 
with  chronic  ovarian  inflammation.  Sterility  is  frequent,  owing  to  the 
destruction  of  the  follicular  elements  or  the  thickening  of  the  fibrous 
capsule,  which  prevents  normal  maturation  of  the  ovaries. 

Physical  Signs. — Pressure  at  Morris'  point  usually  elicits  pain,  and 
on  bimanual  examination  the  ovary  is  felt  as  a  large,  tender  mass,  low 
down  in  the  lateral  or  posterior  fornix,  usually  more  or  less  movable, 
distinct  and  not  blending  with  the  uterus  or  parametrial  tissues;  or  the 
ovary  may,  as  in  the  atrophic  form,  be  smaller  than  normal,  adherent 
and  very  sensitive. 

A  large  ovary  may  be  normal,  its  increased  size  being  due  to  a  simple 
transitory  corpus  luteum  cyst;  while  a  small  ovary  may  be  pathologic. 

Recto-abdominal  examination  is  of  great  value,  for  by  the  rectal 
touch,  one  is  often  able  to  palpate  the  ovary  with  great  facility. 

Prognosis. — The  prognosis  in  chronic  ovaritis  should  always  be 
guarded,  for  the  ovary,  like  the  tube,  has  great  reparative  powers.  A 
spontaneous  symptomatic  cure  may  occur  at  the  menopause,  though  sel- 
dom before,  unless  absolute  sexual  abstinence  is  observed.  Abscess  for- 
mation may  result,  usually  after  puerperal  infection,  or  the  ovary  may 
be  changed  into  a  mass  of  small  cysts,  with  little  or  no  stroma  remaining. 
Sterility  is  a  common  sequel  of  chronic  ovaritis.  The  pathologic  ovary 
never  completely  regenerates. 

Treatment  of  Chronic  Ovaritis. — The  treatment  consists  of  rest 
in  the  recumbent  posture,  especially  at  the  menstrual  period,  and  coun- 
terirritation.  This  may  be  made  with  a  capsicum  plaster  or  the  applica- 
tion of  iodin  to  the  abdomen  over  the  ovarian  region  and  to  the  vaginal 
vault.  The  local  treatment  to  the  vaginal  f  omices  by  iodin  and  the  intro- 
duction of  elastic  wool  tampons  saturated  with  boroglycerite,  may  be 
repeated  once  in  three  days.  These  treatments  are  best  given  with  the 
patient  in  the  knee  chest  position,  for  in  this  way  the  ovary  can  be  raised 
by  the  tampon  and  its  circulation  improved.  The  daily  employment  of 
hot  douches  and  the  keeping  of  the  lower  bowel  empty  tends  to  improve 
the  pelvic  circulation.  The  bowels  should  be  emptied  by  small  doses  of 
cascara  sagrada  and  small  saline  enemata.  Hot  sitz  baths  and  mud 
baths  have  been  employed  in  the  foreign  clinics  for  years,  frequently 
with  some  degree  of  success. 

For  the  pain,  certain  antispasmodics,  as  the  chlorid  of  gold  and 
sodium  gr.  i-io,  or  extract  of  cannabis  indica  in  %  gr.  pills,  or  the  tinct 


192  PELVIC  INFLAMMATION  IN  WOMEN 

of  Pulsatilla  TTt  x,  may  be  given  three  or  four  times  a  day,  beginning 
a  week  before  the  time  of  the  expected  period,  and  continued  during 
the  flow.  Latterly  we  have  used  aspirin  gr.  v,  with  ext.  ovarii  gr.  ii,  in 
the  same  manner,  with  apparently  greater  relief.  The  importance  of 
the  restoration  of  the  general  health  by  hygiene,  air,  and  tonics  should 
never  be  forgotten  in  the  management  of  these  patients. 

When  local  and  systemic  measures  fail,  surgical  intervention  may  be 
employed;  this  includes  liberation  of  the  peri-ovarian  adhesions,  linear 
incision  through  the  fibrous  capsule,  ignipuncture,  wedge  shaped  resec- 
tion of  the  diseased  structure,  and,  in  extensive  structural  change, 
oophorectomy. 

We  have  long  since  come  to  the  conclusion  that  ignipuncture  and 
resection  are  not  curative  procedures  and  frequently  leave  the  ovary 
badly  scarred,  adherent  and  painful,  subsequently  necessitating  its 
removal.  Probably  no  condition  in  woman  places  a  greater  responsibil- 
ity on  the  surgeon  than  the  determination  of  wliat  disposition  he  shall 
make  of  an  ovary  in  a  given  case. 

A  cystic  ovary  is  not  always  a  diseased  ovary,  for  cysts  when  single, 
few,  superficial,  and  rounded,  are  usually  corpus  lutein  cysts  or  dropsical 
follicles  and  do  not  require  surgical  treatment.  When  the  cysts  are 
crowded  together  in  masses  of  irregular  shape,  and,  on  splitting  the  ovary 
to  its  hilum,  are  found  throughout  the  gland,  the  ovary  should  be  extir- 
pated. 

Small  hard  atrophic  ovaries  giving  constant  premenstrual  and  inter- 
menstrual pain  demand  oophorectomy;  however,  a  pure  neurosis  is  not 
an  indication  for  ablation. 

Hypertrophy  of  the  ovary  may  be  the  result  of  a  chronic  inflamma- 
tion, but  is  more  often  due  to  a  chronic  hyperemia  of  mechanical  origin, 
such  as  the  large  ovaries  found  in  pregnancy  or  with  fibroid  tumors. 
Their  stroma  is  made  up  of  fibrous  tissue,  rich  in  spindle  shaped  cells, 
with  a  lack  of  primordial  follicles.  Such  ovaries  do  not  necessarily,  be- 
cause of  their  size,  demand  radical  surgery.  Suspension  of  such  an  ovary 
will  reestablish  its  circulation  and  still  retain  the  ovarian  function. 

On  general  principles^  resection  of  the  ovary  should  be  discouraged. 


CHAPTER    IX 

PELVIC    PERITONITIS 

Causes  of  pelvic  peritonitis — Gonococcic  pelvic  peritonitis — Pyogenic  peritonitis — ■ 
Symptoms ;  chill,  pain,  pulse,  muscular  rigidity,  abdominal  tension,  tympanites, 
nausea  and  vomiting,  constipation — Physical  signs — Treatment  of  pelvic  peri- 
tonitis— Arrest  of   intestinal  peristalsis. 

No  discussion  of  pelvic  infections  in  women  would  be  complete  with- 
out a  consideration  of  peritonitis  as  a  pathological  entity,  for  the  peri- 
toneum is  involved  in  almost  all  inflammations  of  the  uterus,  parametria, 
tubes  and  ovaries  as  an  extension  and  complication  of  the  original  in- 
flammation, and  when  it  occurs,  presents  a  definite  pathology  and  a  typical 
symptomatology. 

Broadly  speaking,  peritonitis  is  an  inflammatory  reaction  on  the  part 
of  the  peritoneum  against  trauma  and  invasion  by  pathogenic  organisms, 
and  when  beginning  in  or  confined  to  the  pelvic  peritoneum,  it  is  usually 
the  result  of  an  extension  of  infection  from  the  uterus  through  the 
tubes  or  through  the  parametrium. 

Causes. — Its  causes  may  be  septic,  gonorrheal,  or  tuberculous  in- 
fection. It  is  always  secondary  to  infections  of  the  uterus,  tubes,  ovaries, 
bladder,  pelvic  cellular  tissues,  intestines  or  vermiform  appendix.  Occa- 
sionally it  is  due  to  septic  infection  following  abdominal  section. 

Gonorrheal  and  tuberculous  peritonitis  nearly  always  proceed  from 
infection  of  the  tul:)es;  on  the  other  hand,  septic  peritonitis  may  result 
from  an  infection  through  the  tubes  or  an  extension  through  the 
lymphatics  of  the  uterus  and  parametrium. 

Gonococcic  Pelvic  Peritonitis. — Gonococcic  pelvic  peritonitis  is 
primarily  the  reaction  of  the  peritoneum  covering  the  tubes,  and  the  re- 
action produced  in  the  peritoneum  of  adjacent  viscera  coming  in  contact 
with  them. 

When  the  gonococcus  invades  the  interior  of  the  tube  and  finds  a  suit- 
able environment  for  its  multiplication,  it  excites  an  endosalpingitis,  the 
underlying  muscles  become  infected,  and  then  the  infection  is  spread 
through  the  lymphatics  to  the  peritoneum,  producing  a  perisalpingitis 
and  pelvic  peritonitis.  As  the  infiltration  of  the  tube  wall  increases,  an 
abundant  fibrinous  exudate  forms,  extending  into  the  subperitoneal  tis- 

193 


194  PELVIC  INFLAMMATION  IN  WOMEN 

sues,  and  as  the  tissue  reaction  continues,  there  is  marked  dilatation  of 
the  vessels,  swelling  of  the  endothelium,  and  an  exudate  is  poured  out  on 
the  serous  surface;  or,  fluid  bearing  gonococci  may  escape  from  the 
free  fim.brial  end  of  the  tube  and  directly  infect  the  contiguous  peritoneum 
and  ovarian  surface. 

The  thickness  of  the  tube  wall  is  of  necessity  enormously  increased 
by  exudate  and  the  infiltration  of  leukocytes.  In  the  early  stage  the 
polynuclears  predominate,  while  later  the  mononuclears  are  more  abun- 
dant. As  the  retrogression  takes  place,  the  polynuclears  decrease,  while 
the  mononuclear  cells  relatively  increase. 

Naturally  the  amount  of  exudate  which  forms  on  the  surface  of 
the  peritoneum  will  vary  with  the  intensity  of  the  peritoneal  reaction. 
If  the  irritation  is  not  very  intense,  a  thin  fibrin  deposit  results,  which 
develops  into  thin  delicate  fibrous  tissue  strands  (cobweb  adhesions). 
In  the  more  virulent  inflammation  a  very  large  amount  of  coagulable 
material  is  exuded.  This  is  granular  for  the  most  part;  but  on  the 
surface  of  this  there  is  a  layer  of  fibrinous  material,  which  results  in 
permanent  organization.  In  other  words,  the  granular  substratum  is 
absorbed  while  the  fibrinous  material  on  the  surface  organizes,  forming 
a  fibrous  membrane,  binding  tube,  ovary,  and  intestine  into  one  con- 
glomerate mass,  the  result  of  the  general  peritoneal  reaction. 

Fortunately,  in  the  gonococcic  form  this  reaction  is  confined  almost 
invariably  to  the  peritoneum  of  the  pelvis  and  that  covering  the  viscera 
contained  therein,  as,  owing  to  the  formation  of  fibrinous  adhesions,  the 
pelvic  cavity  becomes  walled  off  early  in  the  process  by  adhesion  of  the 
omentum,  sigmoid,  and  parietal  peritoneum  and  the  inflammatory  reac- 
tion becomes  localised  in  the  pelzns. 

Pyogenic  Peritonitis. — The  peritoneal  reaction  vv^hich  takes 
place  after  labor,  abortion,  or  intra-uterine  manipulation  or  instrumen- 
tation, is  usually  due  to  the  invasion  of  the  streptococcus  or  the  staphylo- 
coccus. In  this  form  of  infection,  the  reaction  may  be  confined  to  the 
pelvis  or  may  spread  to  the  general  peritoneal  cavity. 

Bacteria  gain  entrance  through  the  genital  tract  by  way  of  the  uterus 
or  through  lacerations  of  the  cer\dx  or  vagina,  and  reach  the  peritoneum 
through  the  lymph  channels  by  contiguity  without  previous  focal  involve- 
ment; or,  the  peritonitis  may  be  secondary  to  some  lesion  where  the  in- 
vading organisms  are  temporarily  halted.  For,  while  the  endometrium  is 
the  chief  port  of  entry,  the  infection  rapidly  spreads  through  the  veins 
and  lymph  channels,  not  only  of  the  endometrium,  but  also  of  the  para- 
metrium, thus  ultimately  reaching  the  peritoneum.  The  escape  of 
infective  material  from  acutely  inflamed  tubes  may  be  the  source  of  the 


PELVIC  PERITONITIS  195 

peritoneal  involvement;  or,  a  walled  off  pelvic  abscess,  or  an  abscess  in 
the  wall  of  the  uterus  may  leak  or  rupture,  and  spread  the  infection  to 
the  adjacent  peritoneum. 

On  reaching  the  surface  of  the  peritoneujTi,  an  inflammatory  reac- 
tion to  this  type  of  bacteria  is  rapidly  diffused  over  its  surface.  The 
extent  of  the  diffusion  depends  on  the  virulence  of  the  infecting  organ- 
ism and  the  resistance  of  the  tissues  (the  peritoneum). 

The  surface  of  the  peritoneum  is  reddened,  the  endothelium  swollen 
and  lusterless  and  covered  with  a  thin  flocculent  exudate,  or  the  exudate 
may  be  serous,  or  seropurulent,  containing  numberless  bacteria.  Few 
adhesions  are  formed,  owing  to  the  rapidity  of  the  reaction  and  the  ab- 
sence of  a  fibrinous  deposit.  This  explains  the  tendency  of  this  form 
of  peritonitis  to  spread  upward  into  the  general  peritoneal  cavity  and 
cause  a  fatal  issue. 

Symptoms. — Chill.  In  the  acute  form  the  disease  may  be  ushered 
in  with  a  chill  or  chilly  sensations,  intense  pelvic  pain  and  tenderness, 
high  pulse  and  temperature,  leukocytosis,  tympanites,  irritability  of  the 
bladder,  and  dysmenorrhea.  A  distinct  chill  or  chilliness  is  more  com- 
mon in  the  pyogenic  than  in  the  gonococcic  form,  for  in  the  former  the 
blood  streami  is  often  invaded  through  lymphatic  extension.  The  initial 
chill  may  be  decisive  and  single  or  may  be  repeated.  Preceding  or  fol- 
lowing the  chill,  there  is  rise  of  temperature  and  a  leukocytosis.  The 
fever  is  relatively  low  in  the  gonococcic  form,  ranging  from  101-103°  F.,' 
usually  higher  in  the  puerperal  form.  The  leukocyte  count  rapidly  rises 
to  20,000  or  25,000,  and  the  polymorphonuclear  percentage  is  85  or 
more.  In  the  gonococcic  form,  leukocytosis  is  not  quite  so  marked,  and 
the  percentage  of  polymorphonuclears  is  less. 

Pain. — The  patient  complains  of  intense  pelvic  pain  as  soon  as  the 
peritoneum  is  involved.  This  pain  is  always  characteristic  of  peritoneal 
irritation  and  is  sharp  and  cutting.  At  first  it  is  localized  in  the  region 
of  the  focus  of  origin,  and  then  is  diffused  over  a  wider  area ;  this  may 
be  due  to  reflex  diffusion  of  sensation,  or  to  the  extension  of  the  peri- 
toneal hyperemia.  The  pain  is  always  aggravated  by  motion,  by  intes- 
tinal peristalsis,  and  by  emptying  the  bladder  or  rectum,  owing  to  the 
hyperemic  condition  of  the  serosa.  Motion  allows  the  sore  surfaces  to 
rub  together  and  causes  pain  such  as  is  observed  when  the  pleura  is  in- 
flamed. In  the  gonococcic  form,  the  severe  pain  usually  subsides  in 
twenty-four  to  thirty-six  hours,  if  the  intestinal  tract  is  kept  at  rest. 
On  the  other  hand,  in  pyogenic  peritonitis  there  is  intense  pain  beginning 
in  the  pelvis  which  rapidly  spreads  over  the  whole  abdomen.-  It  is  con- 
tinuous, and  is  increased  by  movement  or  external  pressure.     Pain  is 


196  PELVIC  INFLAMMATION  IN  WOMEN 

increased  by  suddenly  releasing  the  pressure  of  the  palpating  hand.  There 
is  akvays  excessive  abdominal  sensitiveness,  except  when  the  initial  in- 
toxication is  so  overwhehning  that  the  terminal  nerves  are  insensitive  to 
peripheral  irritation;  then  the  patient  makes  no  spontaneous  complaints 
of  pain. 

Pulse. — The  pidse  is  always  accelerated.  The  rate,  however,  in 
gonococcic  peritonitis  is  not  out  of  proportion  to  the  rise  in  temperature, 
while  in  streptococcic  invasion  the  pulse  not  only  becomes  more  rapid, 
but  progressively  increases  in  rate,  breaking  its  relation  with  the  tempera- 
ture rise,  and,  because  of  the  absorption  of  toxins  or  blood  invasion  by 
the  offending  organisms,  the  cardiac  muscle  is  weakened  and  the  quality 
of  the  pulse  is  always  impaired. 

Muscular  Rigidity — Abdominal  Tension. — Early  in  the  attack,  on 
abdominal  examination  one  may  find  the  entire  abdomen  distended  and 
rigidity  of  the  muscles  in  the  hypogastrium  and  over  both  lower  quad- 
rants. This  is  true,  even  in  the  absence  of  diffuse  pain.  As  the  disease 
subsides,  the  rigidity  becomes  limited  to  the  lower  portions  of  both  recti. 
On  the  other  hand,  if  the  inflammatory  process  tends  to  spread,  the  mus- 
cular tension  increases  and  extends  over  a  greater  area. 

Tympanites. — The  amount  of  abdominal  distention  is  always  consid- 
erable, but  in  peritonitis  occurring  during  the  puerperium,  because  of 
the  laxness  of  the  abdominal  walls,  the  distention  is  extreme.  It  is  most 
marked  where  there  is  a  rapid  diffusion  of  the  infection.  As  the  disease 
progresses,  the  intestinal  wall  becomes  edematous  and  infiltrated,  due 
to  hyperemia,  resulting  in  non-function  of  the  muscle  and  nerves,  hence 
the  tympany  increases.  When  the  activity  of  the  process  subsides,  the 
intestine  gradually  regains  its  muscular  tone  and  the  meteorism  progress- 
ively decreases. 

Nausea  and  Vomiting. — Nausea  and  vomiting  are  neither  common 
nor  persistent  in  pelvic  peritonitis,  for  it  may  be  stated  that,  the  further 
the  inflammatory  reaction  is  removed  from  the  duodenum  and  stomach, 
the  less  prominent  is  the  symptom  of  vomiting.  In  spreading  peritonitis, 
gastric  irritation  may  become  a  symptom  of  great  importance. 

Constipation. — The  bowels  are  usually  inactive  in  the  early  stages  of 
pelvic  inflammation,  owing  to  the  paresis  of  the  terminal  portion  of  the 
large  bowel.  This  is  often  due  to  the  amount  of  fibrinous  exudate  thrown 
out  in  the  peritoneal  reaction,  or,  as  before  said,  to  the  edema  and  infil- 
tration of  the  intestinal  wall.  As  the  inflammatory  changes  subside,  the 
bowel  gradually  regains  its  muscular  tone,  and  is  readily  emptied  with 
small  enemata. 


PELVIC  PERITONITIS  197 

Physical  Signs  (Pelvic). — On  biinamial  examination  there  is  fixity  of 
the  pelvic  organs.  At  first,  this  is  due  to  hyperemia  of  the  peritoneum 
and  muscular  spasm,  but  in  thirty-six  or  forty-eight  hours  the  whole 
pelvis  is  filled  with  a  plastic  exudate  and  the  whole  pelvis  becomes  ex- 
quisitely sensitive. 

This  exudate  fixes  the  contents  of  the  pelvis  as  in  a  plaster  cast,  and 
fills  the  cnl  de  sac  and  the  pelvis  on  either  side  of  the  uterus.  As  the 
mass  becomes  more  dense,  the  sense  of  tumor  is  more  pronounced.  In 
the  streptococcic  form,  pelvic  examination  gives  less  evidence  of  mass, 
for  the  exudate  is  serous  or  seropurulent,  not  plastic.  But  motion  of  the 
cervix,  however,  is  extremely  painful. 

The  density  of  an  inflammatory  tumor  is  often  misleading,  owing 
to  its  extreme  hardness ;  it  may  even  simulate  the  density  of  a  carcinoma. 
The  bulk  of  these  inflammatory  tumors  is  not  produced  by  the  exudate, 
either  in  the  tube  or  around  it,  but  by  an  extensive  edema  of  the  sub- 
peritoneal connective  tissue.  This  fact  is  often  lost  sight  of  and  a  peknc 
abscess  diagnosticated  and  an  unnecessary  operation  advised. 

Time  will  effect  the  most  miraculous  absorption  of  these  tumor 
masses.  When  the  inflammatory  reaction  subsides  and  the  edema 
and  infiltration  lessen,  the  mass  becomes  hard  and  insensitive  and  the 
leukocyte  count  falls.  Should  an  abscess  form,  the  mass  generally  in- 
creases in  size,  the  pain  recurs,  and  the  tumor  becomes  more  sensitive. 
It  may  bulge  into  the  cid  de  sac  and  displace  the  uterus  forward  and 
upward.  Occasionally  it  is  possible  to  elicit  fluctuation.  The  evening 
temperature  is  always  elevated,  the  patient  perspires  freely  in  the  re- 
missions, and  the  leukocyte  count  is  relatively  high. 

Diagnosis. — Certain  symptoms  are  common  to  all  forms  of  periton- 
itis, temperature,  tenderness,  tension  or  rigidity,  abdominal  sensitiveness, 
tympany,  intestinal  paresis  and  gastric  irritation,  and  they  differ  only 
in  their  intensity  and  location. 

Pelvic  peritonitis  has  to  be  differentiated  from  extra-uterine  preg- 
nancy, appendicitis,  and  ovarian  cyst  with  a  twisted  pedicle.  (This 
differentiation  has  already  been  referred  to  in  the  chapter  on  sal- 
pingitis.) 

Prognosis. — The  prognosis  will  depend  largely  on  the  type  of  the 
infecting  organism  and  the  resistance  of  the  individual.  In  the  gon- 
ococcic  type  the  peritoneal  reaction  usually  results  in  resolution,  with 
complete  or  partial  symptomatic  and  anatomic  cure.  Unfortunately, 
owing  to  an  improper  understanding  of  the  clinical  course  of  gon- 
orrheal infection  of  the  peritoneum,  many  cases  are  overtreated  and 
mixed  infections  ensue.     These  lead  to  the  formation  of  peritoneal  and 


198  PELVIC  INFLAMMATION  IN  WOMEN 

visceral  adhesions  of  the  fibrinous  type,  with  encysted  serous  effusions, 
pelvic  abscess  and  spreading  or  diffuse  peritonitis. 

The  outcome  in  puerperal  peritonitis  is  always  more  serious,  for 
during  pregnancy,  and  the  puerperium,  the  lymphatics  are  more  active 
and  the  streptococcus  and  staphylococcus  are  more  virulent  organisms. 
While  proper  treatment  and  timely  intervention  may  arrest  the  ad- 
vance in  many  cases  of  spreading  peritonitis,  we  doubt  that  a  really 
diffuse  case  ever  recovers. 

The  difficulty  in  forming  any  accurate  idea  concerning  the  out- 
come of  reported  cases  lies  in  the  fact  that  observers  differ  so  widely  in 
their  interpretations;  thus,  many  cases  of  spreading  peritonitis  are 
reported  as  diffuse.  Puerperal  cases,  furthermore,  are  always  com- 
plicated by  more  or  less  blood  stream  infection,  and  consequently  the 
heart,  liver  and  kidneys  are  subject  to  greater  degenerative  changes 
and  thus  diminish  the  resistance  of  the  individual. 

To  summarize,  we  would  say  that  the  prognosis  in  gonorrheal 
pelvic  peritonitis,  under  proper  treatment,  is  good  as  to  life;  but  there  is 
always  some  remaining  pathology,  which  may  or  may  not  produce  pelvic 
and  abdominal  symptoms.  On  the  other  hand,  puerperal  peritonitis, 
with  its  tendency  to  spread  into  the  upper  abdomen,  and  the  associated 
infections  in  the  uterus,  parametria  and  pelvic  veins,  always  makes  the 
outcome  as  to  life  serious. 

Treatment  of  Pelvic  Peritonitis. — The  management  of  pelvic 
peritonitis  will  be  considered  under  the  heads  of  (a)  palliative  and  (b) 
operative. 

In  pelvic  peritonitis,  the  type  of  the  infection  not  only  helps  to 
determine  the  prognosis,  but  suggests  the  plan  of  treatment  to  be  adopted. 
In  the  gonorrheal  type,  with  its  typical  history  and  clinical  course,  the 
tendency  is  toward  a  localization  of  the  process  and  a  spontaneous  and 
symptomatic  cure.  This,  of  course,  may  be  followed  by  acute  exacerba- 
tions of  the  old  process;  on  the  other  hand,  in  pelvic  peritonitis  of 
puerperal  and  postabortal  origin,  the  inflammatory  reaction  has  a  greater 
tendency  to  spread  and  involve  a  greater  area  of  the  peritoneum,  and 
consequently  is  more  apt  to  demand  surgical  measures  to  aid  the  arrest 
of  the  inflammation. 

It  has  l^een  difficult  until  recently  to  make  the  surgeon  understand 
that  there  is  a  difference  l^etween  the  peritonitis  following  perforation 
of  the  appendix,  or  a  gastric  or  duodenal  ulcer,  and  the  peritoneal 
reaction  which  takes  place  as  an  extension  of  a  tubal  inflammation  or 
as  a  complication  of  a  parametric  process.  In  the  former,  the  intestinal 
content  is  suddenly  poured  into  the  unprepared  peritoneal  sac  and  the 


PELVIC  PERITONITIS  199 

material  is  diffused  over  a  large  area ;  consequently  the  reaction  on  the 
part  of  the  peritoneum  is  insufficient  to  localize  the  process.  In  pelznc 
peritonitis,  except  in  the  presence  of  a  very  virulent  infection,  the  reac- 
tion is  but  an  extension  of  the  tubal  process,  beginning  as  a  perisal- 
pingitis, and  the  adjacent  peritoneum  has  already  become  hyperemic 
and  has  poured  out  an  exudate  which  tends  to  cause  adhesions  of  the 
contiguous  viscera  and  thus  localize  the  process  within  the  pelvis. 

In  the  former,  surgical  intervention  may  remove  the  cause  and 
thus  stop  the  supply  of  infective  bacteria  and  toxins,  and,  by  properly 
employed  drainage,  favor  the  localization  of  the  peritoneal  reaction  and 
thus  change  a  spreading  peritonitis  into  a  localized  peritonitis.  On  the 
other  hand,  in  pelvic  peritonitis,  localization  of  the  reaction  within  the 
pelvis  has  already  taken  place,  the  pelvis  being  cut  off  from  the  general 
cavity  by  the  adhesion  of  the  sigmoid  to  the  uterus  and  the  bladder, 
and,  in  order  to  remove  or  drain  the  focus,  the  surgeon  is  compelled 
to  spread  the  infection  throughout  the  lower  abdomen;  hence,  palliative 
measures  have  their  greatest  field  in  the  pelvic  type  of  the  disease. 

It  is  the  desire  of  every  surgeon  that  the  inflammatory  reaction  of 
the  peritoneum  be  localized.  This  may  be  greatly  assisted,  except  in 
such  abdominal  calamities  as  perforations  of  the  hollow  viscera,  by 

(a)  Rest, 

(b)  Posture, 

(c)  Arrest  of  intestinal  peristalsis, 

(d)  Opium  for  the  relief  of  pain, 

(e)  Enteroclysis. 

Rest  in  the  semirecumbent  posture  is  the  most  comfortable  position 
for  the  patient,  for  the  flexion  of  the  thighs  relieves  the  strain  on  the 
tense  abdominal  muscles.  When  we  add  to  this  the  Fowler  elevated 
trunk  posture,  as  may  be  obtained  with  the  Gatch  bed.  we  not  only 
favor  gravity  drainage,  by  making  the  pelvic  peritoneum  the  lowermost 
point  in  the  peritoneal  sac,  but  actually  tend  to  localize  the  peritoneal 
reaction  in  the  true  pelvis.  This  is  done  by  adhesion  of  the  oinentuni 
to  the  bladder  and  anterior  parietal  peritoneum,  and  attachment  of  the 
loop  of  the  sicjtmoid  to  the  fundus  and  the  bladder  reflection.  Thus,  any 
low  typed  infective  reaction  within  the  pelvis,  or  the  involvement  of  any 
of  the  viscera  contained  therein,  is  actually  limited  to  the  structures  below 
the  brim. 

Unfortunately,  in  peritoneal  reactions  of  the  puerperal  type,  owing 
to  the  arrest  of  involution,  the  uterus  is  of  larger  size  and  is  usually  zvell 
out  of  the  true  pelvis.    This,  together  with  the  greater  virulence  of  the 


200  PELVIC  INFLAMMATION  IN  WOMEN 

infective  organisms  and  the  increased  size  of  the  lymphatic  channels, 
consequent  upon  the  pregnant  state,  offer  larger  channels  for  absorption ; 
therefore,  the  infection  is  more  difficult  to  confine  within  the  pelvis  and 
we  are  more  likely  to  meet  with  the  spreading  type,  for  the  uterus 
with  its  perimetritis  is  carried  into  the  field  of  diffusion.  Even  in  this 
type,  clinical  experience  has  convinced  us  that  there  are  advantages  from 
the  routine  use  of  the  Fowler  posture. 

Intestinal  peristalsis  must  be  arrested,  for  motion  of  the  intestines 
rubs  the  hyperemic  surfaces  together,  and  always  causes  or  increases  the 
peritoneal  pain;  besides  this,  the  peristalsis  diffuses  the  infective  material, 
and  thus  causes  an  extension  of  the  inflammatory  reaction  in  the  peri- 
toneum. 

To  obtain  intestinal  quiet,  all  cathartics  and  laxatives  are  withheld, 
no  food  is  given,  and  sufficient  opium  must  be  administered  to  control 
peristalsis.  In  our  clinic  morphin  in  one-eighth  grain  doses  is  given 
hypodermatically  at  four  hour  intervals.  This  has  seemed  to  control 
the  pain  and  intestinal  activity,  without  producing  any  ill  effects.  Small 
and  repeated  doses  given  at  regular  intervals  of  three  or  four  hours 
have  a  better  effect  on  the  course  of  the  disease  and  the  morale  of  the 
patient  than  a  larger  quantity  given  irregularly  or  only  when  the  woman 
is  in  severe  pain. 

On  general  principles,  all  food  should  be  withheld  as  long  as  opiates 
are  being  given.  The  vomiting  in  pelvic  peritonitis  is  of  less  frequent  oc- 
currence and  less  persistent  than  in  peritoneal  reactions  due  to  invasion  of 
the  upper  abdominal  cavity. 

The  nausea  and  vomiting  usually  cease  when  food  and  fluids  are 
withheld  and  neither  nourishuient  nor  medication  is  given  by  mouth. 
Should  the  vomiting  persist  after  withholding  food  and  fluids,  gastric 
lavage  will  generally  effect  its  cessation.  Little  gagging  will  be  occasioned 
if  a  small  sized,  smooth  tipped,  well  lubricated  stomach  tube  is  passed 
through  the  nose.  This  should  be  connected  by  a  glass  T,  connecting  tulDe 
with  a  reservoir  containing  a  gallon  of  warm  saline  or  bicarbonate  of 
soda  solution.  A  piece  of  rubber  tubing  should  be  attached  to  the  base 
of  the  T  as  an  outflow  tube.  After  the  tul^e  is  in  the  stomach,  the 
outflow  tube  is  clamped,  and  about  a  pint  of  fluid  allowed  to  run  into 
the  stomach;  when  a  clamp  is  placed  on  the  tube  coming  from  the  res- 
ervoir, and  the  one  on  the  outflow  tube  is  removed,  the  stomach  con- 
tents will  be  withdrawn.  This  procedure  is  repeated  until  the  stomach 
washings  are  clear  and  free  from  bile  staining.  Performing  lavage 
in  this  way  gives  less   distress  to  the  patient  and  assures  complete 


PELVIC  PERITONITIS  201 

emptying  of  the  stomach  content.  Lavage  also  relieves  the  gas  distention 
in  the  upper  abdomen. 

Tympany  is  seldom  a  very  troublesome  symptom  in  pelvic  peritonitis, 
yet  gas  distention  does  occur  and  may  cause  the  patient  considerable 
distress.  In  most  cases  the  distention  may  be  readily  controlled  by  the 
routine  use  of  the  "Harris  drip"  after  the  lower  bowel  has  been 
emptied  of  its  fecal  masses  by  a  small  low  enema  of  soap  suds. 

The  Harris  drip  consists  of  a  gallon  douche  can  reservoir,  half  filled 
with  a  warm  solution  of  five  per  cent  glucose  in  bicarbonate  of  soda,  or 
with  warm  tap  water  which  is  kept  warm  by  placing  an  incandescent 
lamp  in  the  can.  The  can  is  placed  on  a  small  stand  at  the  side  of  the 
bed,  and  the  bottom  of  the  can  should  he  at  the  level  of  the  symphysis 
pubis.  About  two  feet  of  rubber  tubing  is  attached  to  the  outlet  of  the 
can,  and  to  this  is  attached,  by  a  glass  connecting  tube,  an  ordinary 
rectal  tube  of  small  caliber.  The  rectal  tube,  well  vaselined  and  with 
all  of  the  air  expelled  from  it,  is  now  introduced  into  the  rectum  for 
a  distance  of  four  to  six  inches.  This  allows  the  fluid  to  run  into 
the  rectum  and  sigmoid  until  it  has  reached  the  level  of  the  fluid  in 
the  can,  which  insures  that  a  single  column  of  fluid  at  low  pressure  fills 
the  can,  tube  and  sigmoid. 

The  level  of  the  fluid  in  the  can  changes  slightly  with  inspiration 
and  expiration  under  the  gradual  distention  of  the  sigmoid  and  the  ob- 
literation of  the  sigmoid  angle;  and,  once  the  sigmoid  angle  is  obliterated, 
gas  usually  passes  freely  back  into  the  can  and  the  contained  fluid 
becomes  stained  with  fecal  matter.  Gradually  the  abdominal  distention 
and  tension  get  less  and  less. 

Since  we  have  discontinued  the  use  of  large  and  irritating  enemata  in 
our  peritonitis  cases,  distention,  pain  and  thirst  have  been  seldom 
noted,  unless  there  was  an  extension  of  the  process;  furthermore,  the 
amount  of  fluid  taken  up  in  this  way  by  the  sigmoid  and  colon  is 
sometimes  enormous.  This  naturally  increases  the  blood  pressure, 
stimulates  the  kidney  function  and  dilutes  the  toxins,  while  the  absorp- 
tion of  glucose  maintains  the  body  heat. 

In  addition  to  the  foregoing  palliative  methods,  it  has  been  the  rule 
to  use  either  heat  or  cold  to  relieve  the  local  pain.  Heat  properly  applied 
to  the  surface  of  the  abdominal  wall  tends  to  relax  the  muscular  spasm, 
increase  the  local  hyperemia,  and  relieve  the  pain  due  to  the  local 
peritoneal  reaction.  Heat  also  seems  to  act  favorably  upon  the  dis- 
tention. We  have  used  heat  in  both  the  dry  and  moist  form  and  feel 
that,  when  there  is  any  considerable  amount  of  abdominal  distention  or 
tension,  dry  heat  acts  most  kindly. 


202  PELVIC  INFLAMMATION  IN  WOMEN 

In  using  dry  heat  we  employ  the  Gellhorn  baker,  first  covering  the 
abdomen  with  a  sheet,  or,  what  is  better,  with  a  bath  towel,  and  then 
placing  the  baker  over  the  abdomen,  maintaining  a  constant  heat  of 
130°  to  140°  F.  This  degree  of  heat  can  be  comfortably  borne  for 
hours  without  burning  or  blistering  the  skin.  A  local  hyperemia  is 
produced  in  the  tissues  of  the  abdominal  wall,  and  the  stasis  favors 
phagocytosis.  It  is  sometimes  amazing  to  see  the  relaxation  and  com- 
fort which  come  from  the  continuance  of  this  measure. 

Where  a  Gellhorn  or  Bier  heater  is  not  available,  moist  heat  may 
be  substituted  in  the  form  of  the  hot  antiphlogistine  or  clay  poultice. 
The  hot  clay  is  applied  directly  to  the  abdominal  wall  and  covered  with 
a  layer  of  cotton  batting  or  six  or  eight  thicknesses  of  gauze;  this, 
in  turn,  is  covered  with  a  hot  water  bag  which  has  been  but  partially 
filled  to  lighten  the  weight.  This  is  held  in  place  on  the  abdomen  and 
over  the  poultice  by  a  many  tailed  binder.  These  clay  poultices  need 
not  be  renewed  oftener  than  once  in  twenty-four  hours.  Moist  heat  is 
particularly  grateful  when  applied  over  painful  exudates. 

Cold  is  sometimes  a  better  anesthetic  than  heat  when  used  to  relieve 
the  pain  over  a  local  inflammatory  process.  It  does  not,  however,  give 
the  degree  of  relaxation.  The  too  long  continued  use  of  either  heat 
,or  cold  can  produce  serious  pathological  changes  in  the  skin. 

To  summarize,  the  palliative  treatment  of  pelvic  peritonitis  is  rest, 
starvation,  opium  and  enteroclysis,  with  the  applicaton  of  heat  or  cold  to 
relieve  the  local  pain.  If  this  treatment,  properly  carried  out,  is  doing 
good,  and  nature  is  competent  to  meet  and  overcome  the  advance  of 
the  invader,  the  temperature  should  fall,  the  evening  elevations  should  be 
less  each  day,  the  tension,  distention  and  tenderness  should  diminish, 
and  the  leukocyte  count  and  the  polymorphonuclear  percentage  decrease; 
with  the  improvement  in  these  general  symptoms  the  general  condition 
and  well  being  of  the  patient  should  show  marked  improvement.  When 
the  patient  shows  no  local  or  general  improvement,  palliative  and  symp- 
tomatic measures  must  give  place  to  surgery. 

A  spreading  peritonitis  is  evidenced  by  the  persistence  or  the  recur- 
rence of  sharp  colicky  pains,  diffused  over  the  abdomen  and  not  relieved 
by  ordinary  doses  of  morphin ;  the  tension  and  distention  seem  intract- 
able, vomiting  may  persist  or  recur,  the  temperature  remains  elevated, 
the  pulse,  due  to  poisoning  of  the  cardiac  muscle,  loses  its  tone  and  be- 
comes more  rapid,  the  leukocyte  count  is  usually  30,000  or  more,  and 
the  polymorphonuclear  cells  over  85  per  cent. 

Spreading  peritonitis  demands  drainage.  Get  in,  drain,  and  get  out 
cjuickl^,  i§  th^  accepted  principle.    It  matterg  not  v/heth^r  the  dr^^inage 


PELVIC  PERITONITIS  203 

is  made  through  the  cul  de  sac  of  Douglas  or  through  the  abdominal 
wall. 

During  the  past  winter  we  have  saved  several  lives  in  cases  of 
spreading  postabortal  peritonitis,  with  seropurulent  exudate,  by  making 
a  free  ciil  de  sac  incision  through  the  vaginal  vault  and  isolating  the 
pelvis  (after  the  Pryor  method)  by  placing  small  rolls  of  iodoform 
gauze  in  the  recto-uterine  pouch  across  the  pelvis  from  side  to  side. 
The  incision  temporarily  relieves  the  abdominal  tension  and  allows 
the  escape  of  the  seropurulent  exudate.  This  diminishes  the  absorption 
of  toxins,  while  the  gauze  promptly  excites  a  peritoneal  reaction,  as  is 
shown  in  the  rise  of  the  leukocyte  count  and  the  relative  fall  in  the 
percentage  of  polymorphonuclear  cells.  These  cases  have  promptly  be- 
come localized,  and  the  abdominal  and  general  symptoms  have  subsided. 

In  others,  under  novocain  and  gas,  we  have  made  a  stab  wound 
incision  in  the  abdominal  wall  just  above  the  pubis  and  drained  through 
the  abdomen.  There  is  no  need  of  looking  about  for  the  origin  of  the 
infection  or  sponging  or  rvashing  out  the  exudate  from  the  peritoneum. 
Intra-abdominal  pressure  and  posture  will  do  all  that  is  possible  to 
do  in  aiding  nature  to  wall  off  and  localize  the  process.  After  this 
simple  and  direct  surgery  in  the  form  of  drainage  has  been  done,  the 
general  plan  of  palliative  treatment  already  described  is  carried  out 
until  the  final  issue  is  obtained.  Many  cases  of  spreading  peritonitis  are 
lost  by  allowing  them  to  become  diffuse  before  drainage  is  established. 
//  drainage  is  done  promptly  and  without  unnecessary  trauma,  nature 
has  a  breathing  spell  and  is  temporarily  relieved  of  excessive  toxin 
absorption,  in  which  time  she  is  often  competent  to  change  the  character 
of  the  process. 

In  those  cases  of  pelvic  peritonitis  which  result  in  a  pelvic  abscess, 
the  physical  signs  usually  make  the  diagnosis;  for,  following  the  initial 
symptoms  of  the  acute  peritoneal  reaction,  with  the  pouring  out  of  a 
plastic  exudate,  the  uterus  is  pushed  forward  and  upward  by  a  sensitive, 
exudative  mass,  filling  the  posterior  and  lateral  cul  de  sac.  The  tumor 
mass  gradually  enlarges  and  forces  the  uterus  above  the  pubis,  while 
the  mass  bulges  downward  along  the  sides  of  the  rectum  and  points 
into  the  rectum  or  vagina.  The  enlargement  causes  pelvic  pain  and 
tenesmus. 

Such  a  pelvic  mass  is  best  opened  through  the  vagina  by  a  wide  in- 
cision in  the  cul  de  sac  through  the  vaginal  vault,  as  described  under 
posterior  colpotomy.  The  majority  of  pelvic  abscesses  are  the  result 
of  mixed  infection,  an  infection  in  which  the  Qolon  bacillus  takes  a 
prominent  part. 


CHAPTER   X. 

TUBERCULOUS  PERITONITIS 

Tubercle  bacilli  in  the  peritoneum — Secondary  involvement  by  the  blood  stream,  by 
contiguity,  or  by  continuity — No  well  defined  symptomatology — Exudative,  ad- 
hesive, and  caseous  forms — Clinical  diagnosis  difficult — Prognosis — Climate — Tu- 
berculin— Operation. 

Tuberculous  peritonitis  is  a  primary  or  secondary  infection  of  the 
peritoneum  by  the  tubercle  bacillus. 

Many  of  the  cases  of  the  so-called  idiopathic  peritonitis  are  prob- 
ably tubercular  in  origin,  while  the  cause  is  the  invasion  of  the  peri- 
toneum by  the  tubercle  bacillus.  Certain  etiological  factors  contribute 
to  the  conditions  and  circumstances  under  which  the  disease  develops. 

No  age  is  exempt.  Cases  have  been  reported  as  occurring  in  the 
first  week  of  life,  while  others  are  recorded  in  patients  of  over  seventy. 
The  disease  is  most  frequent,  however,  between  the  twentieth  and  the 
forty-ninth  year  (Osier).  The  largest  proportion  of  our  own  cases 
have  occurred  in  women  under  thirty. 

From  a  review  of  the  available  statistics,  it  would  seem  that  about 
three  times  as  many  males  are  affected  as  females;  but  as  the  gynecolo- 
gist sees  only  women,  he  gets  an  erroneous  impression  of  the  sex 
incidence.  It  is  generally  agreed  that,  in  the  majority  of  cases  in  the 
female,  the  genital  organs  are  the  point  of  origin,  for  Heintze  claims 
that  the  pelvic  congestions  of  puberty,  menstruation,  pregnancy,  and 
pelvic  peritonitis  all  predispose  to  tuberculous  peritonitis.  Kelly  be- 
lieves that  there  is  a  definite  relation  between  pregnancy  and  tuberculous 
peritonitis.  In  twenty-eight  per  cent  of  his  cases  the  disease  dated 
from  childbirth.  In  support  of  this  view,  BouUand  states  that  the  fre- 
quent congestion  consequent  upon  menstruation  and  pregnancy  favors 
the  development  of  tuberculosis,  and  we  all  know  that  pregnancy  in- 
creases the  activity  of  the  tubercular  process  in  the  lungs. 

Heredity 'has  apparently  nothing  to  do  with  the  occurrence  of  tuhcr- 
cidosis  of  the  peritoneum,  for  a  family  history  of  tuberculosis  is  ob- 
tained in  less  than  one  sixth  of  the  cases.  Notwithstanding  this  clinical 
fact,  Hane  claimed  to  have  found  a  positive  tubercular  history  in  thirt)^ 
five  per  cent  of  his  cases.    Our  own  experience  has  been  that  tuberculous 

204 


TUBERCULOUS  PERITONITIS  205 

peritonitis  may  attack  those  who  have  no  tuberculous  history  and  who 
have  been  previously  in  good  health. 

The  disease  may  be  primary,  or  secondary.  Primary  peritoneal 
tuberculosis  is  relatively  infrequent,  for  a  primary  lesion  can  be  proved 
only  in  the  rarest  instances.  The  fallopian  tubes  are  apparently  the 
most  frequent  primary  seat  of  tuberculosis  in  the  female  peritoneum. 
Mayo  has  reported  twenty-six  cases.  Osier  estimates  that  thirty  to 
forty  per  cent  are  primary  in  the  tube,  and  Konlich  places  the  incidence 
as  high  as  seventy-one  per  cent.  Even  in  these  reported  instances,  the 
possible  preexistence  of  a  primary  focus  elsewhere  cannot  be  denied. 

The  secondary  form  is  an  extension  from  other  organs.  Owing 
to  the  rarity  of  the  primary  form,  it  is  naturally  inferred  that  when 
we  find  peritoneal  tuberculosis,  it  is  probably  secondary  to  a  tuberculous 
lesion  elsewhere.  Therefore,  the  problem  which  confronts  us  is  to  find 
the  focus  and  to  determine  how  the  infection  travels  from  the  primary 
focus  to  the  peritoneum. 

The  incidence  of  tuberculous  peritonitis  and  the  occurrence  of  tuber- 
culosis in  other  parts  of  the  body,  as  shown  by  autopsy  records,  will 
throw  some  light  on  this  subject.  Cummins,  quoted  by  Hertzler,  in 
3405  autopsies  collected  from  the  Pennsylvania,  Philadelphia,  and  Uni- 
versity hospitals,  found  some  form  of  tuberculosis  in  835,  or  twenty- 
four  per  cent  of  the  cases  observed;  in  addition,  76  showed  healed  foci. 
Tuberculous  peritonitis  was  found  in  92  autopsies,  or  2.7  per  cent  of  tlie 
entire  number,  or  in  eleven  per  cent  of  the  tuberculous  cases.  Nothnagel, 
Munstermann,  and  others,  confirm  these  figures;  hence  it  may  be  assumed 
that  the  peritoneum  is  involved  in  approximately  ten  per  cent  of  the 
cases  when  death  is  caused  by  tuberculosis  of  some  other  organ  of  the 
body.  Kroenig  found  that  the  relative  frequency  of  the  organs  involved 
was  as  follows :  the  lungs  in  92  per  cent ;  the  intestines  in  74  per  cent ; 
the  kidney  in  35  per  cent;  and  generalized  involvement  in  10  per  cent. 
Cummins'  records  showed  the  lungs  to  be  involved  in  84  per  cent, 
and  the  intestines  in  32  per  cent;  the  tubes  and  adnexa  in  40  per  cent, 
and  the  urinogenital  organs  in  8  per  cent.  Klebs  believes  that  the  in- 
testinal tract  is  the  common  avenue  of  infection.  The  chief  argument 
in  favor  of  this  view  is  the  relative  frequency  of  mesenteric  glandular 
tuberculosis  in  children.  He  assumed  that  the  bacilli  could  gain  access 
to  the  lymph  or  blood  stream  and  then  gain  a  foothold  in  any  part 
of  the  body,  escaping  the  lymph  glands  and  involving  the  peritoneum 
primarily. 

When  the  primary  focus  is  known,  the  secondary  involvement  of 


2o6  PELVIC  INFLAMMATION  IN  WOMEN 

the  peritoneum  may  take  place  by  one  of  the  following  routes,  namely, 
by  the  blood  stream,  by  contiguity,  by  continuity. 

An  instance  of  hematogenous  infection  is  where  the  peritoneum 
becomes  involved  as  a  part  of  a  general  miliary  tuberculosis. 

Extension  by  contiguity  may  be  illustrated  by  the  approach  of  the 
infection  from  the  lungs  to  the  pleura.  Here  the  lesion  may  be  traced 
along  the  lymph  vessels  from  the  lungs  to  the  pleura.  The  extension  in 
the  lymphatics  may  take  place  directly  from  one  lesion  to  another,  pro- 
pelled by  retrograde  metastasis,  due  to  the  central  occlusion  of  the  lymph 
vessels  by  the  central  tuberculous  lesion.  Contiguous  lesions  may 
coalesce  and  a  continuous  lesion  result. 

Extension  by  continuity  is  by  direct  extension  without  the  inter- 
vention of  any  uninfected  tissue.  The  most  common  example  of  ex- 
tension by  continuity  is  infection  of  the  peritoneum  by  extension  through 
the  walls  of  the  fallopian  tubes.  After  the  tubercle  bacilli  have  gained 
access  to  the  peritoneal  surface,  the  dissemination  takes  place  by  diffusion 
and  by  gravity. 

The  tubercle  when  located  in  the  peritoneum  does  not  differ  from  the 
tubercle  situated  in  any  other  tissue.  The  tubercle  is  the  unit  lesion  of 
tuberculosis  and  may  be  described  as  "a  small  grayish  granule,  semi- 
transparent,  sometimes  transparent  and  colorless,  and  of  consistency  a 
little  less  than  that  of  cartilage;  their  size  varies  from  that  of  a  millet 
seed  to  that  of  a  hemp  seed;  in  form  they  are  oblong  at  first  glance, 
but  are  less  regular  when  examined  with  a  magnifying  glass,  when  they 
sometimes  appear  to  be  angular;  they  are  intimately  attached  to  the 
underlying  tissue  and  cannot  be  separated  from  it  without  causing  shreds 
of  tissue  to  follow."    (Baillie.) 

The  cause  of  their  oblong  form  is  that  their  long  axis  is  parallel  with 
the  lymph  vessel  supplying  the  area  affected.  This  is  explained  by  the 
fact  that  bacteria  travel  most  readily  along  natural  channels.  The  larger 
nodules  result  from  a  limitation  of  such  extension  by  a  process  of  be- 
ginning fibrosis ;  therefore  the  larger  nodules  represent  an  older  process. 
The  very  fine  lesion  is  seen  in  the  more  acute  cases,  while  the  larger 
tubercle  is  usual  in  the  case  of  slowly  developing  disease.  The  tendency 
of  all  tuberculous  lesions  is  to  undergo  caseation,  when  they  lose  their 
transparency  and  become  opaque  and  cheesy. 

In  hyperacute  lesions  the  general  appearance  of  the  peritoneum  may 
be  one  of  acute  hyperemia  with  edema.  The  fine  tubercles  can  only 
be  made  out  on  close  inspection,  but  the  nodulation  may  be  recognized 
by  the  sense  of  touch.  The  tubercle  bacillus  may  produce  diffuse  in- 
filtration without  forming  cirgwmscribed  lesions;  thus  the  intestine  may 


TUBERCULOUS  PERITONITIS 


207 


be  thickened  to  a  centimeter  or  more  for  a  considerable  area,  without 
the  appearance  of  tubercles. 

In  the  early  stages,  when  there  is  a  diffuse  dissemination  of  tubercles, 
the  irritation  produces  an  exudation  of  fluid  and  ascites  is  the  result. 
Whether  this  remains  as  a  simple  fluid  accumulation,  or  results  in  a 
fibrinous  exudate,  depends  on  the  amount  of  fibrin  elements  which  the 
exudate  contains.  If  these  are  slight,  either  from  too  limited  irritation 
or  from  the  presence  of  too  great  toxicity,  the  fibrin  cannot  form,  and  the 
adhesive  type  does  not  result.  Excessive  fibrin  must  be  deposited  to 
produce  the  adhesive  type.    The  adhesive  type  is  the  least  virulent  of  all. 

Combination  of  the  serous,  fibrinous  and  caseous  types,  which  are.  in 
reality  but  different  stages  of  the  tubercular  lesion,  are  well  shown  in 
primary  pelvic  tuberculosis,  in  which  the  tube  itself  is  caseous  with 
fibrinous  adhesions  about  it,  and  an  abundant  crop  of  newer  tubercles 
develop  over  the  remainder  of  the  peritoneum,  giving  rise  to  a  serous 
exudate. 

The  simplest  practical  classification  is  that  the  disease  occurs  in  the 
exudative,  the  adhesive,  and  the  caseous  form. 

In  the  early  stages  of  the  lesion,  three  characteristics  are  recognized : 

( 1 )  Superficial  location, 

(2)  Small  size, 

(3)  Absence  of  reaction  in  the  surrounding  peritoneum. 

Tuberculosis  heals  by  the  same  process  in  the  peritoneum  as  in 
other  locations.  Bumm  has  described  the  healing  of  the  tuberculous 
lesion  by  the  following  steps: 

1.  Cell  infiltration  of  the  tubercle  and  its  environment; 

2.  Degeneration  of  the  giant  cells  and  epithelioid  elements 

of  the  tubercles ; 

3.  Increase  of  the  surrounding  connective  tissue  and  incapsula- 

tion  of  the  tubercles  and  finally  the  formation  of  a  scar 
nodule. 

Symptoms. — The  onset  is  variable  and  insidious  for  there  is  no  well 
defined  and  clear  cut  symptomatology.  Many  peritoneal  lesions  simulate 
tubercular  peritonitis.  The  prodromal  symptoms  may  extend  over 
many  years,  or  the  onset  may  be  sudden,  as  in  the  case  of  a  perforation. 
There  is  commonly  a  history  of  general  ill  health  zvith  exacerbations. 

The  acute  cases  begin  either  as  an  acute  infectious  disease,  or  as  an 
abdominal  crisis.    Chill,  fever,  headache,  vertigo  and  malaise  characterize 


2o8  PELVIC  INFLAMMATION  IN  WOMEN 

the  former  type,  while  vomiting,  distention  and  pain  mark  the  onset  of 
the  latter.  The  conditions  may  be  combined.  When  fever  and  malaise 
predominate,  typhoid  fever  may  be  simulated.  This  resemblance  is 
heightened  by  distention  and  general  abdominal  tenderness  and  pain. 
In  this  acute  form  the  chief  symptom  is  continuous  high  temperature. 
Sometimes  there  is  a  roseolar  exanthem  and  swelling  of  the  spleen.  Not 
all  cases  of  this  type  begin  so  abruptly ;  for  instance,  a  case  with  rapidly 
developing  malaise  may  present  no  other  symptom  than  an  increase  of 
girth,  or  continual  bladder  irritation  may  be  the  first  symptom;  or,  the 
peritoneal  infection  may  be  overshadowed  by  the  severity  of  the  general 
infection.  Complicating  pleural  and  pulmonary  involvement  are  recog- 
nized by  pain,  signs  of  an  exudate,  and  respiratory  disturbance. 

The  chronic  type  is  characterized  by  an  indefinite  onset ;  the  malaise, 
general  weakness,  indefinite  pain  in  the  abdomen,  and  possibly  in- 
testinal disturbances,  may  exist  for  months  before  the  actual  diagnosis 
is  made.  Local  symptoms,  as  leukorrhea  or  referred  pains,  common 
to  irritation  of  the  pelvic  organs,  dysmenorrhea,  sacral  pains,  may  be 
present  when  the  pelvic  peritoneum  is  involved.  Periodic  or  persistent 
constipation  with  localized  pain  in  some  region,  notably  in  the  region  of 
the  umbilicus,  less  often  in  the  region  of  the  ileocecal  valve,  may  be  the 
first  symptoms  of  the  disease.  In  most  cases  where  there  is  a  sudden 
onset,  the  disease  is  in  the  miliary  stage. 

In  the  fibrinous  type,  when  fluid  is  present  in  the  peritoneal  cavity,  the 
increase  in  girth  may  be  the  first  sign ;  for,  notwithstanding  the  progres- 
sive weakness,  the  patient  seems  to  be  gaining  flesh.  The  outline  of  the 
abdomen  is  usually  characteristic  and  the  enlargement  is  general,  in- 
volving all  regions  of  the  abdomen  alike.  Fluid  is  first  detected  in 
the  flanks. 

In  the  purely  serous  cases,  where  there  are  no  adhesions,  the  fluid 
changes  its  level  with  a  change  of  position.  Hertzler  claims  that  in 
tuberculous  peritonitis  the  wave  obtained  by  tapping  is  less  distinct 
than  in  other  exudates  of  like  magnitude,  and  that  when  the  position 
of  the  patient  is  changed,  the  line  of  the  upper  layer  of  the  fluid  changes 
less  promptly  than  in  other  forms  of  ascites.  There  may  be  bulging 
in  the  cid  de  sac  of  Douglas  on  vaginal  palpation.  The  amount  of  fluid 
may  not  be  great,  or  may  be  as  much  as  six  gallons. 

The  adhesive  type  may  be  associated  with  or  follow  the  ascitic,  or 
may  occur  independently.  The  onset  presents  much  the  same  sequence 
of  symptoms.  Coils  of  intestines  become  adherent  to  each  other  or  to  the 
omentum,  which  allow  pockets  to  form.  These  become  filled  with  fluid 
and   present   the   physical   characteristics   of   cysts.      These   cysts    are 


TUBERCULOUS  PERITONITIS  209 

more  apt  to  form  in  the  upper  abdomen.  When  the  adhesive  type  in- 
volves the  pelvis,  a  thickened  tube  may  be  found  to  have  anchored 
the  uterus,  and  the  bulging  fluid,  walled  off  above  by  the  adherent 
sigmoid,  may  present  a  sacculated,  semifluid  resistance  on  either  side 
of  the  tubal  ridge.    Constipation  and  digestive  disturbances  are  common. 

In  the  caseous  type  there  is  no  free  fluid.  There  are  bosselated 
masses,  including  loops  of  intestine;  consequently  there  is  great  dis- 
turbance of  intestinal  mobility.  The  process  frequently  ulcerates  through 
the  intestinal  wall,  and  a  mixed  infection  follows  in  the  retroperitoneal 
spaces.  The  uterus  is  nearly  always  fixed,  and  the  omentum,  which  is 
thickened  and  rolled  upon  itself,  presents  itself  as  a  palpable  tumor.  The 
infiltrated  surfaces  of  the  parenchymatous  organs,  like  the  liver  and 
spleen,  serve  to  complicate  the  picture. 

Digestive  disturbances  are  at  their  height  in  this  type.  Pain,  tym- 
pany, and  diarrhea  occur,  while  the  fever  increases  as  the  disease 
progresses.  The  umbilicus  may  be  distended,  everted,  and  reddened, 
showing  distended  capillaries  near  its  border  and  radiating  veins  over  the 
contiguous  skin.    This  sign  is  of  great  diagnostic  value  when  present. 

Tuberculosis  of  the  pelvic  peritoneum  is  usually  associated  with  a 
tuberculous  endosalpingitis  and  a  perisalpingitis.  Primary  miliary 
tuberculosis  of  the  tubes  is  said  to  be  uncommon.  Williams  is  of  the 
opinion  that  the  disease  primarily  involves  the  mucosa,  approaching  the 
peritoneum  secondarily.  This  is  in  accord  with  the  fact  that  the  com- 
monest form  is  the  caseous.  Many  recorded  cases  fail  to  confirm  the 
infrequency  of  the  miliary  type.  Breaking  down  of  tissue  is  apt  to  be 
early,  and  once  the  lesion  approaches  the  peritoneal  surface,  early  at- 
tachment to  the  surrounding  surfaces  takes  place.  This  explains  the 
formation  of  the  pelvic  mass  by  matting  together  of  the  adnexa  and 
adjacent  organs. 

Clinically,  the  surgeon  must  make  the  differential  diagnosis  from  the 
small  cyst  like  nodules  which  form  as  a  result  of  a  chronic  irritative 
process.  These  cysts  are  identical  in  structure  with  the  stalked  hydatids 
so  commonly  observed  hanging  from  the  fimbriated  ends  of  the  tubes. 
They  are  miliary  cysts  filled  with  a  clear  fluid.  The  cyst  walls  are 
composed  of  a  very  fine  layer  of  connective  tissue  and  are  lined  with  flat 
endothelium  and  covered  by  the  same  kind  of  cells.  They  owe  their 
origin  to  the  deposition  upon  the  surface  of  the  peritoneum  of  any  floccu- 
lent  precipitate  and  the  formation  over  this  of  a  pseudoperitoneum 
which  gives  rise  to  actual  peritoneal  cysts.  Over  the  fundus  of  the 
uterus  these  cysts  may  be  as  large  as  peas,  or  even  larger.  The  larger 
ones  readily  collapse  when  punctured,  but  the  small  ones  cannot  be  recog- 


210  PELVIC  INFLAMMATION  IN  WOMEN 

nized.  The  lack  of  any  reactive  process  about  them,  either  vascular  or 
indurative,  and  the  semitransparent  appearance,  are  sufficient  to  differ- 
entiate them  from  tubercles.  Sometimes  there  are  small  granular  nodules 
which  appear  much  like  the  cysts,  but  which  are  made  up  of  granulation 
tissues  covered  by  a  new  endothelium  layer.  These  are  less  transparent 
than  the  cysts,  and  may  attain  the  size  of  a  pin  head  or  a  split  pea. 
Occasionally  foreign  body  giant  cells  are  found  in  them. 

Subperitoneal  tuberculosis  of  so  slight  a  degree  may  exist  that  its 
nuture  may  not  be  suspected  until  the  suspected  tissue  is  sectioned.  If  it 
be  a  tube,  it  is  often  possible  to  detect  the  diseased  area  by  palpation  when 
it  is  not  discernible  to  inspection. 

The  indurative  type,  in  which  the  subperitoneal  tissue  is  extensively 
hyperplastic,  may  closely  resemble  gonorrheal  salpingitis.  If  caseated 
areas  are  discovered,  or  if  tubercles  are  seen  about  the  border  of  the 
process,  the  tuberculous  nature  of  the  disease  may  be  recognized,  or 
section  of  the  tissue  will  show  fine  granulations  suggestive  of  tuber- 
culosis. Miliary  areas  of  necrosis  are  sometimes  noted  in  gonorrheal 
tubes.  A  localized  thickening  of  the  tube  may  be  caused  by  tuberculosis, 
presenting  a  veritable  salpingitis  nodosa.  These  nodules,  when  sectioned 
by  the  knife,  present  caseated  areas.  While,  many  times,  tubal  tubercu- 
losis and  tubercular  peritonitis  are  recognized  at  the  operating  table,  fre- 
quently cases  must  be  followed  to  the  laboratory  before  a  positive  diag- 
nosis can  be  made. 

The  clinical  diagnosis  of  tubercular  salpingitis  and  peritonitis  is 
difficult.  A  certain  small  proportion,  about  one  fourth,  may  be  diagnos- 
ticated by  carefrdly  considering  the  history  and  physical  signs;  but  the 
great  majority  are  not  recognized  until  the  abdomen  is  opened. 

In  known  cases  of  tuberculous  peritonitis,  the  tubercle  bacillus  can 
be  demonstrated  in  only  about  50  per  cent.  The  most  certain  method 
of  demonstrating  the  bacilli  is  by  injecting  the  exudative  fluid  into  the 
peritoneal  cavities  of  guinea  pigs  or  rabbits.  Yet  this  necessarily  fails 
because  the  bacilli  arc  usually  in  the  tuberculous  tissue,  and  not  in  the  free 
fluid. 

The  reaction  from  the  inoculation  with  tuberculin  is  unreliable,  be- 
cause the  patient  may  have  healed  lesions  and  there  is  commonly  an  ex- 
isting process  in  some  other  part  of  the  body.  The  reaction  may  be 
regarded  as  suggestive  and  somewhat  confirmatory,  but  not  diagnostic. 

Very  little  of  positive  diagnostic  value  can  be  obtained  by  chemical 
reactions.  Tuberculous  exudates  may  have  a  higher  specific  gravity 
than  is  found  in  other  ascitic  accumulations ;  on  the  other  hand,  the  exu- 
dative changes  in  the  peritoneum  may  be  sufficient  to  block  some  of 


TUBERCULOUS  PERITONITIS  211 

the  mesenteric  veins  and  thus  reduce  the  specific  gravity ;  hence,  reliance 
on  the  specific  gravity  of  the  exudate  is  confusing,  and  has  no  clinical 
significance. 

The  albumin  content  is  greater  in  tuberculous  peritonitis  than  in 
other  abdominal  dropsies ;  the  average  is  from  three  to  five  per  cent. 

The  cell  content  of  the  peritoneal  exudate  in  tuberculosis  is  apt  to  be 
richer  in  small  mononuclear  leukocytes  than  in  the  ascites  of  cirrhosis  or 
carcinoma. 

Judd,  of  the  Mayo  clinic,  suggests  a  valuable  clinical  test  to  make  the 
diagnosis  at  the  operating  table.  He  pours  peroxid  of  hydrogen  into 
the  peritoneal  cavity,  washing  it  away  with  saline  solution.  The  peroxid 
produces  a  frosted  appearance  of  the  surface,  which  when  removed  by 
the  saline,  leaves  the  unaffected  portion  of  the  peritoneum  a  normal  pink 
color,  and  the  tubercles  stand  out  as  a  pearly  white  on  a  pink  back- 
ground. 

Theoretically,  the  leukocyte  count  should  be  low,  and  should  aid 
materially  in  differentiating  tuberculosis  from  acute  suppurating  diseases ; 
but  experience  shows  it  to  be  of  little  clinical  value. 

Some  elevation  of  temperature  is  always  present  in  tuberculosis  in 
the  acute  and  subacute  stages,  if  we  take  the  rectal  temperature.  It 
is  usually  highest  in  the  evening,  and  normal  or  subnormal  in  the 
morning.  It  may  run  a  course  which  may  clinically  simulate  typhoid ;  but 
the  absence  of  a  positive  Widal  and  of  the  typical  rose  colored  spots 
excludes  the  latter.  The  history  of  the  presence  of  other  tuberculous  foci 
may  furnish  the  clew  to  the  diagnosis. 

A  large  collection  of  fluid  in  the  abdomen  suggests  tuberculous  peri- 
tonitis in  children.  The  subcutaneous  veins  situated  about  the  umbilicus 
are  distended  in  4.4  per  cent  of  the  cases. 

Pelvic  examination  shows  a  diffuse  infiltration  of  the  cul  de  sac, 
or  the  cervix  may  be  enlarged,  soft  and  cyanotic.  I  have  mistaken  tuber- 
culous pelvic  disease  for  pregnancy. 

Rontgen  examination  of  the  abdomen  may  be  p'^acticed,  following 
oxygen  inflation  of  the  peritoneal  cavity;  involved  glands  and  adhesions 
are  often  brought  to  view  by  this  method,  as  well  as  fluid  inclusions. 
It  may  be  of  help.  My  experience  is  too  limited  to  give  a  definite  opinion, 
but  it  certainly  appears  worthy  of  further  investigation. 

Prognosis. — From  a  review  of  the  literature,  it  would  seem  that 
more  persons  recover  now  than  formerly ;  this  may  be  due  to  the  fact  that 
a  large  per  cent  are  diagnosticated,  or  because  a  greater  number  are 
operated  upon.  Certainly  the  operative  treatment  has  made  possible  a 
closer  study  of  the  lesions  in  the  early  stages.     The  diagnosis  is  never 


212  PELVIC  INFLAMMATION  IN  WOMEN 

certain  without  a  direct  inspection.  As  it  has  become  generally  under- 
stood that  the  operative  treatment  is  the  correct  procedure,  doubtful 
cases  are  subjected  to  celiotomy  and  thus  given  the  benefit  of  operation. 
Hygienic  and  sanatorium  treatment  of  the  primary  lung  involvement 
saves  many  patients  from  peritoneal  complications. 

From  65  to  85  per  cent  recover  after  operative  treatment.  Pic  ol> 
served  sixty-four  cases  of  young  girls  with  tubercular  peritonitis.  Un- 
treated, 50  per  cent  died.  The  best  results  seem  to  be  in  the  exudative 
form.  The  prognosis  in  the  ulcerative  and  suppurative  forms  is  very 
grave.  The  best  prognosis  is  seen  in  women  in  whom  the  disease  began  in 
the  adnexa  and  who  were  treated  by  removal  of  the  adnexa.  Such  cases 
give  75  per  cent  recoveries  in  the  exudative  form  and  50  per  cent  in 
the  adhesive  variety.  In  the  poorly  nourished,  and  those  living  under 
unfavorable  hygienic  conditions,  recovery  is  naturally  less  likely  than 
in  those  whose  constitutional  and  environmental  conditions  are  more 
favorable. 

Treatment. — The  chief  agents  to  be  directed  against  the  disease 
are  the  natural  defenses  of  the  body.  Occasionally  definite  conditions 
arise  where  active  operative  interference  is  warranted.  Where  it  is 
possible  to  remove  the  focus  of  infection,  operation  offers  a  prospect  of 
relieving  the  patient  of  this  part  of  her  burden. 

The  conservative  treatment  consists  in  the  exhibition  of  drugs, 
climatic  treatment,  radiotherapy,  tuberculin,  and  abdominal  paracentesis. 
The  less  said  about  the  use  of  drugs  the  better,  for  aside  from  general 
tonics,  no  drug  has  seemed  to  have  any  beneficial  or  specific  effect  on 
the  process. 

Climate. — Both  Leroux  and  Lalesque  are  of  the  opinion  that  sea 
air  is  particularly  useful  after  the  acute  symptoms  have  subsided. 

X-ray  Therapy. — The  X-ray  has  been  used  more  or  less  extensively 
with  varying  results.  Rays  from  hard  or  medium  hard  tubes  are  used, 
and  the  patient  is  given  daily  seances  for  three  or  four  weeks;  but  the 
available  reports  fail  to  show  any  marked  influence  of  the  X-rays  on 
the  course  of  the  disease.  Direct  sun  rays,  as  suggested  by  Oppenheimer, 
seem  to  have  beneficial  results.  He  believes  that  the  sun's  rays  pro- 
duce a  hyperemia  of  the  peritoneum  and  thus  increases  the  reaction  of 
the  tissues  to  the  infection. 

Tuberatlin. — Little  that  is  favorable  can  be  attributed  to  the  employ- 
ment of  tuberculin  injections;  our  own  experience  has  not  led  to  en- 
thusiasm. 

Paracentesis,  followed  by  the  use  of  oxygen  gas  in  the  exudative 
form,  has  recently  been  used  with  claimed  success.     In  cases  where  the 


TUBERCULOUS  PERITONITIS  213 

fluid  content  of  the  abdomen  can  be  definitely  demonstrated,  simple 
puncture  and  drawing  off  of  the  accumulated  fluid,  followed  by  the 
injection  of  oxygen  gas  through  the  cannula,  may  produce  a  slight  in- 
flammatory reaction, which  may  check  the  progress  of  the  disease.  Mc- 
Glinn  opens  the  abdomen  and  inflates  it  repeatedly  with  oxygen.  This 
is  really  safer  than  paracentesis,  as  it  avoids  the  possibility  of  puncture 
of  the  intestine  and  injury  to  the  blood  vessels. 

Operation. — Laparotomy  for  tuberculous  peritonitis  is  not  without 
danger.  The  primary  mortality  has  been  recorded  as  between  three  and 
ten  per  cent  from  collapse,  sepsis,  and  fecal  fistulae;  besides  these  dan- 
gers, it  subjects  the  patient  to  the  possibility  of  mixed  infection.  The 
exudate  is  at  first  beneficial,  in  that  it  contains  a  tubercle  antitoxin, 
which  is  alone  sufficient  to  effect  a  cure  in  mild  cases;  hence,  operation 
is  not  indicated  early  in  the  process,  but  after  it  has  become  subacute,  in 
the  third  or  fourth  month  after  the  onset  of  the  process. 

General  opinion  is  in  favor  of  operation  after  the  acute  symptoms 
have  subsided.  The  abdomen  should  be  opened  by  a  free  median  in- 
cision, so  that  ample  opportunity  is  given  for  thorough  inspection.  The 
fluid  is  evacuated,  but  adhesions  are  better  left  undisturbed.  The  applica- 
tion of  peroxid  of  hydrogen  or  of  the  tincture  of  iodin  to  the  diseased 
peritoneal  surfaces  has  apparently  given  the  best  results.  Mayo  and 
others  insist  on  the  removal  of  the  tubes.  By  this  method  he  claims 
twenty-five  recoveries;  in  seven  of  these,  simple  laparotomy  had  al- 
ready been  performed.  We  believe  that  in  primary  isolated  lesions 
of  the  tube,  where  local  thickening  with  caseation  is  present,  the  tube 
should  be  removed ;  but  we  cannot  see,  when  the  process  is  more  or  less 
general,  why  the  infected  tube  should  be  removed  any  more  than  we 
should  remove  the  infected  omentum  or  intestine.  We  have  removed 
the  tubes  in  tuberculosis  of  the  peritoneum,  supposed  to  be  of  pelvic 
origin,  when  we  have  failed  to  find  tuberculosis  in  the  tube  on  subse- 
quent bacteriological  examination.  Operation  probably  does  good  by 
the  active  and  passive  hyperemia  which  is  produced. 


INDEX 


Abdominal  tension,   in  pelvic  peritonitis, 

196 
Abortion,  involuntary,  due  to  gonorrhea, 

35,  36 

—  septic    infections    in    connection    with, 

characteristic  features  of,  66 
Abscess,  appendicular.     See  Appendicular 
Abscess 

—  of  Bartholin's  gland,  differential  diag- 

nosis of,  3,  4 

formation  of,  3 

treatment  of,  by  dilation,  4 

by  excision  of  gland,  5 

by  incision,  5 

—  parametric.     See  Parametric  Abscess 

—  pelvic.     See   Pelvic  Abscess 
Abscesses,  gonorrheal,   in   Skene's  glands 

or  mucous  glands  of  the  urethra,  38 
Adhesions,  intestinal,  in  salpingitis,  139 
in  tuberculous  peritonitis,  208 

—  visceral,  in  salpingitis,   136,  138 
Anemia,   of  fibrosis   uteri,   130 
Anodyne,  occasional  necessity  of,  in  gon- 
orrheal urethritis,  57 

Antigonococcal  applications  to  vaginal 
vault,  in  acute  gonorrheal  vaginitis, 
59 

Antigonococcic  solutions,  use  of,  in  treat- 
ment of  gonorrheal  infection,  55 

Appendicitis,  differentiated  from  salpin- 
gitis,  142 

Appendicular  abscess,  differentiated  from 
pyosalpinx,  146 

Atrophic  ovaritis,  190 

Bacillus    aerogenes    capsulatus,    constant 

inhabitant  of  vulva,  65 
^history  of,   64 

—  nature  and  action  of,  64 

—  resistance  of  man  to,  65 
Bacillus  coli,  nature  and  action  of,  64 
Bacteria,    avenues    of    entrance    for,    in 

puerperal   infections,   67 

—  of  the  genital  region,  68 

—  infective,  cocci  and  bacilli,  62 
Bacteriemia,  autopsy  findings  in,  103 

—  avenues  of  entrance,  102 
lymphatic,   102 

puerperal  wound,  103 

vascular,  102 

—  bacteriology  of,   102 

—  definition  of,  102 


Bacteriemia,  due  to  pelvic  exudates  of 
cellulitis,  89 

—  local  pathological  reaction  of,  103 

—  lymphatic,  102,  103 

—  process  of,  119 

—  prognosis  of,  107 

—  symptoms  of,  104 

—  treatment  of,  119 

by    development   of   a   leukocytosis, 

120 

by  injections,   119 

by  transfusion,  120 

—  vascular,   102,    103 

Bacteriology    of    pelvic    infections.      See 

Pelvic    Infections,   Bacteriology   of 
Bartholinitis,   associated    with   gonorrheal 

vulvitis,   38 
Bartholin's     ducts     and     glands,     abscess 

of,  3 
differentiated  from  other  conditions, 

3,  4 

formation  of,  3 

treatment  of,  by  dilation,  4 

by  excision  of  gland,  5 

by  incision,  5 

anatomy  of,  3 

—  gonorrheal  infection  of,  abscess  forma- 

tion in,  3 

differentiated  from  other  condi- 
tions, 3,  4 

treatment  of,  4 

pathology  of,  o 

persistent  nature  of,  3 

symptoms  and  physical  signs  of,  3 

—  red  raised  macula  about  orifice  of,  3 
Bell-Beuttner  operative  technic,   170 
Birth    traumatisms,    as    avenues    of    en- 
trance for  bacteria,  67 

Blindness,  due  to  gonorrhea,  36 
Blood  supply,  effect  on,  of  cellulitis,  88 
Blood    transfusions,    repeated,    small,    in 
thrombophlebitis,   100 

Cancer  of  the  cervix,  endocervicitis  dif- 
ferentiated from,  19 

—  long-continued  cervical  inflammation  a 

prodrome  of,  20 

Carcinoma  of  the  uterus,  differentiation 
of  chronic  metritis  from,  131 

Catharsis,  avoidance  of,  in  pelvic  infec- 
tions, 114 

in  salpingitis,  150 


2IS 


2l6 


INDEX 


Cauterization,  linear,  of  Hunner  and  Rus- 
sell,  for  endocervicitis,  22 

—  in  treatment  of  gonorrheal  infection  of 

Skene's  glands,  3 

Cellular  tissue,  pelvic,  increase  in  amount 
of,  during  pregnane}',  83 

location   of,  81 

involved  in  puerperal  pelvic  cel- 
lulitis, 82,  83 

Cellulitis,  of  broad  ligament,  accompany- 
ing gonorrheal  inflammation  of  fal- 
lopian tubes,  49 

—  pelvic,  attending  pelvic  phlebitis,  97 
avenues  of  entrance,  85 

—  —  exudates  of,  amount  of,  affecting  the 

blood  supply,  88 

—  bacteremia  due  to,  89 

classification  of.   Von  Rosthorn's, 

86 

directions  taken  by,  86 

extent  and  consistence  of,  87 

lateral,  87 

origin  of,   93 

protective    tissue     reaction    with, 

87 

suppuration  of,  89 

termination  of,  89 

chronic,  90 

complicated  by   femoral  thrombosis, 

90 

by  phlegmasia  alba  dolens,  90 

definition   of,  81 

differential   diagnosis   of,   92 

— from  peritonitis,  93 

from  thrombosis,  septic,  of  pelvic 

veins,  93 
due  to  infections  from  traumatisms 

of  the  vagina  and  cervix,  82 

etiology  of,  84 

factors  affecting  severity  of,  84 

history  of,  90.  93 

location   of   cellular  tissue  involved, 

82,  83 
location  of  cellular  tissue  in  the  pel- 
vis, 81 

pathology  of,  85 

physical  signs  of,  92 

primary,  a  sequel  of  infected  labor 

or  operative  procedures,  93 

prognosis  of,  93 

rare,  after  abortion,  85 

symptoms  of,  90 

acute    localized,    91 

history,  90,  93 

pain,  91 

physical  signs,  92 

varicosities  due  to,  88 

—  posterior,    attending    endocervicitis,    l8 

—  prognosis  of,  106 


Cervical  infection,  presence  of,  in  chronic 
pelvic  inflammation,  52 

Cervical  leukorrhea,  as  symptom  of  endo- 
cervicitis, 17,  18 

Cervical  mucosa,  structure  and  function 
of,  15 

Cervicitis,  gonorrheal,  chronic  cystic, 
treatment  of,  60 

conditions     increasing    susceptibility 

to,  40 

frequency  of,  40 

histology  of,  41 

process  of,  in  acute  stage,  40 

in  chronic  stage,  40 

Cervix,  cancer  of.  See  Cancer  of  the 
Cervix 

—  examination  of,   for  gonorrheal  infec- 

tion, 54 

—  subjection    of,    to    severe    trauma    and 

laceration,  in  labor,  75 

—  syphilitic  ulceration  of,   19 

—  tuberculosis   of.     See   Tuberculosis   of 

the  Cervix 
Chill,  as  a  symptom  of  pelvic  peritonitis, 

195 
Cold,  application  of,  in  pelvic  peritonitis, 

202 
Colpitis.     See  Vaginitis 
Colpotomy,  posterior,  in  treatment  of  pus 

tubes,  indications  for,   153 

technic  of,  154 

Complement  fixation  test,  for  diagnosis  of 

gonorrhea,  33 
Condyloma    acuminata,    composition    and 

structure  of,  38 

—  definition  of,  37 
Constipation,  in  pelvic  peritonitis,  197 
Curettage,   dangers  of.   111 

—  indication  for,  111 

—  in    treatment   of    chronic   metritis    and 

fibrosis  uteri,   133 

—  —  of  endocervicitis,  23 

Cyst,  inclusion,  of  lower  vaginal  wall,  dif- 
ferentiated from  abscess  of  Bartho- 
lin's gland,  4 

—  retention,   of   vulvovaginal  gland,   dif- 

ferentiated  from  abscess  of   Bartho- 
lin's gland,  4 
Cystic  ovary,  191 

Delivery,  aseptic,  underlying  principles 
of,  107 

—  prophylactic     measures     against    puer- 

peral infection  during,  107,  108 
Diabetic  vulvitis,  cause  of,  9 

—  description  and  symptoms  of,  9 

—  treatment  of,  9 

Dilation  of  Bartholin's  duct,  for  abscess, 
4 


INDEX 


217 


Douches,  hot,  in  fibrosis  uteri  and  chronic 
metritis,   132 

—  uterine,  objections  to,  110 

—  vaginal,  in  salpingitis,  151 
Drainage,   with  posterior   colpotomy,   for 

pus  tubes,  indications   for,  153 
procedure,  156 

—  postural,  of  genital  tract,  in  treatment 

of  gonorrheal  infection,  55 

—  in   spreading   pelvic   peritonitis,   202 

—  uterine.     See  Uterine  Drainage 
Drugs,  in  treatment  of  metritis,  chronic, 

and  fibrosis  uteri,  132 
Dyschezia,   as  a    symptom  of    salpingitis, 

141 
Dysmenorrhea,  of  fibrosis  uteri,  130 
Dysuria,  in  salpingitis,  141 


Edema,      of      thrombophlebitis      of     the 

femoral  or  saphenous  vein,  95 
Endocervicitis,   acute,    14 

—  —  of   gonorrheal  origin,  treatment  of, 

20 

—  chronic,  clinical  course  of,  17 
definition  of,  14 

diflferentiated  from  cancer  of  cervix, 

19 

from  tuberculosis  of  the  cervix, 

19 

etiology  of,  15 

pathology  of,  16 

prevalence  of,  14 

prognosis   of,  20 

sterility  due  to,  18 

symptoms  of,  18 

leukorrhea,  17,  18 

metrorrhagia,  18 

posterior  cellulitis,  18 

treatment  of,  20 

by  cauterization,  after  technic  of 

Hunncr  and  Russell,  22 

by  curettage,  23 

dry,  of  Gellhorn  and  Curtis,  21 

operative,  24 

Sturmdorf's  technic,  26 

palliative,  harmfulness  and  futil- 
ity of,  21,  24 

by  radium,  24 

—  definition  of,   14 

—  gonorrheal,  treatment  of,  20 

— long-continued,  a  prodrome  of  cervical 

cancer,  20 
Endometritis,       bacteriemia       developing 

from,  102 

—  diagnosis  of,  infiltration  of  leukocytes 

in,  41 

presence     of     plasma    cell     in,     41, 

42 


Endometritis,  endometrial  changes  for- 
merly described  as,  merely  phases  of 
the  menstrual  cycle,  41 

—  gonorrheal,  acute,  42 

histology  of,  42 

symptoms  of,  43 

termination  of,  43 

causation       and       occurrence       of, 

41 

chronic,  42 

histology  of,  44 

symptoms  of,  45 

diagnosis  of,  42 

diagnosis  of,  43 

differentiated  from  septic  endometri- 
tis of  streptococcic  variety,  44 

histology  of,  acute,  42 

chronic,  44 

infrequency    of,    as    compared    with 

cervicitis,  43 

leukorrhea   most   constant   symptom 

of,  45 

menstrual  disturbances  in,  45 

not  a  pathological  entity,  except  in 

conjunction  with  tubal  infection,  41, 
46 

points  suggesting  spread  of  infec- 
tion to  adnexa,  44 

as  a  self-limited  infection,  41 

symptoms   of,   acute,  43 

chronic,  45 

treatment  of,  60 

—  puerperal,  according  to  Bumm,  12 
cause  of,  74,  75 

coccal,  80 

frequency  of,  74 

limitation  of  infection  to  interior  of 

uterus,  IZ 

to  placental  site,  IZ 

pathology   of,   71 

as  primary  lesion  in  postabortal  and 

puerperal  infections,  11 

putrid  or  saprophytic,  78 

cause  and  process  of,  79 

prognosis  of,  79 

symptoms  of,  79 

symptoms  of,  81 

treatment  of,  109 

—  putrid,  with  poor   drainage,  treatment 

of.  111 
prognosis  of.  106 

—  septic,  of   streptococcic  variety,  differ- 

entiated from  gonorrheal.  44 
Endometrium,    invasion    of,    by    infective 
bacteria.  123 

—  puerperal,     description     of,    in    putrid 

form,  12) 

local  changes  in,  70 

nature  of,  70 


2l8 


INDEX 


Endometrium,  substances  in,  aflFecting 
hemorrhage,  thrombokinase  and 
thrombolysin,  129 

Endosalpingitis.  tuberculous,  associated 
with  tuberculous  peritonitis,  210 

Endosalpinx,  as  beginning  of  gonorrheal 
inflammation  of  fallopian  tubes,  46, 
49 

Enemata,  danger  of,  in  presence  of  gonor- 
rheal discharges,  7 

—  prohibited   in   gonorrheal   infection,   56 
Excision  of  Bartholin's  gland,  for  abscess 

or  cyst,  5 
Exudates,  pelvic,  bacteremia  due  to,  89 

classification  of.  Von  Rosthorn's,  86 

direction  taken  by,  86 

effect  of,  on  blood  supply,  88 

extent  and  consistence  of,  87 

lateral,  87        - 

origin  of,  93 

protective  tissue  reaction  with,  87 

suppuration  of,  89 

termination   of,  89 

Fallopian  tubes,  displacements  of,  in  sal- 
pingitis, 137 

—  gonorrheal  inflammation  of.     See  Gon- 

orrheal Inflammation 

—  inflammation  of.     See  Salpingitis 

—  resection  of,  partial,  clinical  value  as  a 

conservative  operation,  160 

—  rupture  of,  in  salpingitis,   139 

Fecal  tumors,  differentiated  from  pyosal- 
pinx,  144 

Femoral  thrombophlebitis.  See  Throm- 
bophlebitis 

Fever,  puerperal,  cause  of,  74,  75 

frequency  of,  74 

mortality  from,  74 

See  also  Puerperal  Fever 

Fibrosis  uteri,  allied  with  chronic  metritis, 
123 

—  definition  of,  123 

—  differential  diagnosis  of,  131 

—  etiology  of,  129 

—  occurrence  of,    129 

—  prognosis  of,  131 

—  signs  and  symptoms  of,  anemia,  130 
dysmenorrhea,    130 

hardness  and  enlargement  of  uterus, 

130 

hemorrhage,  130 

leukorrhea,  130 

pain,  130 

drugs,  132 

galvanism,  132 

hot  douches,  132 

indications  for,  131 

rest,  132 


Fibrosis    uteri,    signs    and    symptoms    of, 

surgical,   curettage,    133 

hysterectomy,  134 

radium,  133 

vaginal  tamponade  or  pack,  132 

Focal  infections,  puerperal,  69 

endometritis,  71 

ulcers,  69 

Follicular  vulvitis,  causes  and  symptoms 

of,  8 

—  description  of,  8 

—  treatment  of,  8 

Formulae,  of  ointment  for  relief  of  pru- 
ritis,  9 

—  of  skin  protective  for  relief  of  pruritis, 

9 
Fowler  elevated  trunk  posture,  109 

Gall-bladder  inflammation,  differentiated 
from  salpingitis,  143 

Galvanism,  in  treatment  of  chronic  me- 
tritis and   fibrosis  uteri,  132 

Gas  bacillus  infection,  diagnosis  of,  122 

—  symptomatology  of,  121 

—  treatment  of,   122 

Gellhorn   and    Curtis,    dry    treatment    of, 

for  endocervicitis,  21 
Gellhorn    baker,    for    heat    application    in 

pelvic  peritonitis,  202 
Gonococcic  pelvic  peritonitis,*  194 

—  prognosis  of,   198,  199 
Gonococcus  of  Neisser,  action  of,  62 

—  date  of  discovery  of,  31 

—  demonstration   of    presence   of,   micro- 

scopically, difficulties  of,  31,  32 
essential  to  diagnosis  of  gonorrhea, 

31 

of  gonorrheal  vaginitis,  11 

of  gonorrheal  vulvitis,  7 

—  description  of,  31 

—  endotoxin  of,  63 

—  latent,  63 

—  nature  of,  63 

—  preeminently  a  surface  germ,  62 

—  reinfection  by,  34,  35 

—  rules  for  microscopical  identification  of, 

31 

—  surfaces  susceptible  to  infection  by,  3"? 

—  susceptibility     to     other    infection     in- 

creased by,  34,  50 

—  virulence  of,  34 

increased     on     association     with     a 

mixed  infection,  63 
Gonorrhea,  abortion,  involuntary,  due  to, 

35,  36 

—  bacteriological  diagnosis  of,  conditions 

rendering  difficult,  32 

of  highest  medical  and  medicolegal 

importance   and  prognostic  value,  31 


INDEX 


219 


Gonorrhea,  blindness  due  to,  36 

—  cervical,  39 

conditions     increasing     susceptibility 

to,  40 

frequency  of,  40 

histology  of,  41 

process  of,  in  acute  stage,  40 

in  chronic  stage,  40 

See  also  Gonorrheal  Cervicitis 

—  chronicity  of,  34 
-^condyloma  acuminata,  Z7 

—  cure  of,  bacteriological  evidence,  31 

—  evidence    of,    by    complement    fixation 

test,  2>2> 

—  diagnosis  of,  bacteriological,  31,  32 

by  complement  fixation  test,  iZ 

by  vaccination,  Z2> 

—  evil  effects  of,  general  and  vi'idespread, 

35 

—  frequency  of,  35 

—  frequency  of  cervix  infection,  40 

—  general  considerations  of,  31 

—  gonococcus  essential  cause  of,  31 

—  latent,  locations  of,  2>7 
in  Skene's  tubules,  38 

—  period  of  inoculation,  34 

—  points    suggesting    spread   of   infection 

to  the  adnexa,  44 

—  primary  seat  of  infection,  34 

—  process  of,^  34 

—  reinfection  of  gonococci,  34,  35 

—  salpingitis  due  to,  135 

—  sterility  due  to,  35,  36 

—  susceptibility    to    other     infection     in- 

creased by,  34 

—  symptoms  of,  continuance  of,  after  ces- 

sation of  all  signs  of   active  inflam- 
mation, 35 

—  transmission  of,  32i,  34 

at  one  time  and  not  another,  36 

reinfection,  34,  35 

—  venereal   warts   due   to,   or   condyloma 

acuminata,  2)7 

—  See  also  Gonorrheal   Infection  of  Fe- 

fnale  Genitals 

Gonorrheal  cervicitis,  chronic  cystic,  treat- 
ment of,  60 

Gonorrheal  discharges,  enemata  danger- 
ous in  presence  of,  8 

Gonorrheal  endocervicitis,  treatment  of, 
20 

Gonorrheal  endometritis,  acute,  42 

histology  of,  42 

^  symptoms  of,  43 

termination  of,  43 

—  causation  and  occurrence  of,  41 

—  chronic,  42 

histology  of,  44 

symptoms  of,  45 


Gonorrheal  endometritis,  diagnosis  of,  41, 

42,  43 

—  differentiated  from  septic  endometritis 

of  the  streptococcic  variety,  44 

—  histology  of,  acute,  42 
chronic,  44 

—  infrequency  of,  as  compared  with  cer- 

vicitis, 43 

—  leukorrhea  most  constant  symptom  of, 

45 

—  menstrual   disturbances  in,  45 

—  not  a  pathological  entity,  except  in  con- 

.  junction       with       tubal       infection, 
41,  46 

—  points  suggesting  spread  of  infection  to 

adnexa,  44 

—  as  a  self-limited  infection,  41 

—  symptoms  of,  acute,  43 
chronic,  45 

—  treatment  of,  60 

Gonorrheal  infection,  acute,  most  com- 
mon points  of,  1 

—  of    Bartholin's    ducts    and    gland,    ab- 

scess formation  in,  3 

differentiated  from  other  condi- 
tions, 3,  4 

treatment  of,  4 

persistent  nature  of,  3 

symptoms   and   physical   signs   of,   3 

—  of  Skene's  glands,  diagnosis  of,  2 
persistent  nature  of,  1 

treatment  of,  2 

Gonorrheal  infection  of  female  genitals, 
confinement  of,  to  vulvovaginal  ori- 
fice by  the  intact  hymen,  53 

—  cure  of,  determination  of,  61 

—  examination  for,  of   cervix,  54 
of  external  os,  54 

necessity  of  bacteriologic  proof,  54 

maculae  gonprrheae  of  Sanger,  54 

of  urethra,  54 

—  favorite  time  for  extension  of  a  cervix 

gonorrhea,  56 

—  gonorrheal  vaginitis,  58 

—  latent,  in   Skene's  tubules,  58 

—  local    applications,    irrigations,    instru- 

mentation   contra-indicated    in    acute 
stages,  60 

—  maculae  gonorrhcae  of  Sanger,  54 

—  resistance  to,  in  children,  53 

lessened,     in     vagina     of     pregnant 

woman,  54 
of    non-pregnant   adult,    54 

—  treatment    of,    in    acute    specific    ure- 

thritis. 57 

antigonococcic  solutions,  55 

in  cervicitis,  chronic,  cystic.  60 

cleanliness,  necessity  of,  55 

cleansing  of   external  genitalia,   56 


220 


INDEX 


Gonorrheal  infection,  treatment  of,  com- 
plete eradication  of  infection,  by 
destruction  of  the  gonococcus  in  in- 
volved areas,  53,  56 

diet  and  copious  water  drinking,  55 

of  gonorrheal  endometritis,  60 

during  menstruation,  56 

nature's  establishment  of  immunity, 

56 

physical  rest,  55 

postural    drainage   of   genital    tract, 

55 

prevention  of  upward  extension,  53, 

54,  56 

rectal  examinations,  enemata,  sup- 
positories, etc.,  prohibited  during 
acute  stage,  56 

too  active,  61 

two  general  principles  to  be  recog- 
nized, 53 

vaginal  douches  contra-indicated  in, 

56 

vulvar  irrigations,  55 

wiping  of  vulva,  55 

—  treatment  of  results  of,  60 

—  variability   of   individual   immunity  to, 

57 
Gonorrheal    infection    of    Skene's    gland, 

latent,    reinfection    of    urethra    from, 

58 
Gonorrheal     inflammation     of     Fallopian 

tubes,      accompanying     cellulitis      in 

broad  ligament,  49 

—  beginning  of,  46 

—  beginning  of,  as  endosalpinx,  46,  49 

—  bilateral  nature  of  the  disease,  46 

—  characteristics  peculiar  to,  46 

—  inflammatory  exudate  of,  49,  50 

—  parametrial  involvement,  46 

—  pyosalpinx,   as    termination    of    gonor- 

rheal salpingitis,  47 

—  resulting     in      contiguous      peritonitis, 

46 

—  salpingitis,  definite  microscopic  appear- 

ances in,  47 

histology  of,  47 

termination  of,  as  pyosalpinx,  47 

Gonorrheal     inflammation     of     Fallopian 

tubes    and    ovaries,    acute,    symptoms 

of,  51 

—  acute  exacerbations  of,  52 

—  cervical  infection  in,  52 

—  clinical  course  of,  48 

—  chronic,  history  of,  52 
symptoms  of,  52 

—  menstrual  disturbances  in,  52 

—  prognosis  of,  52 

Gonorrheal   metritis,   pathology   and   his- 
tology of,  45 


Gonorrheal  salpingitis,  definite  micro- 
scopic appearances  in,  47 

—  dififerentiated    from    tubercular    perito- 

nitis of  indurative  form,  211 

—  histology  of,  47 

—  prognosis  of,  147 

—  symptomatic  cure  of,  148 

—  terminations  of,   137 

—  termination  of,  as  pyosalpinx,  47 
Gonorrheal  urethritis,   abscess   formation 

in,  38 

—  pain  during  act   of   micturition,  57 

—  process  of,  38 

—  treatment  of,  fundamental  principle  of, 

58 

injection  of  urethra,  57 

occasional  necessity  of  anodyne,  57 

—  reinfection,    from    latent    infection    in 

Skene's  tubules,  58 

for  relief  of  pain  during  fact  of  mic- 
turition, 57 

too  active,  58 

Gonorrheal  vaginitis,  11 

—  acute,  treatment  of,  58 

antigonococcal  applications  to  vag- 
inal vault,  59 

of   external  cervix,  and  external 

OS,  59 

vaginal  douches,  58 

—  avoidance    of    douches    or    irrigations 

during  acute  stage  of,  13 

—  diagnosis  of,  histologically,  39 
clinically,  39 

difficulties  of,  39 

on  microscopic  section,  39 

—  presence  of  gonococcus  microscopically 

demonstrated,    necessary    to    definite 
diagnosis,  11 

—  process  of,  in  acute  stage,  39 

—  prognosis  of,  12 

—  symptoms  of,  12 

—  treatment  of,  13 

Gonorrheal  vulvitis.  Bartholinitis  associ- 
ated with,  38 

—  occurrence  of,  7 

—  peculiarities  of,  Zl 

—  presence  of  gonococcus  microscopically 

demonstrated,    necessary    to    definite 
diagnosis,  7 

—  symptoms  of,  7 

—  treatment  of,  7 

—  urethritis  associated  with,  38 
Granular  vaginitis,  11 


Harris  drip,  description  and  use  of,   156 

in  pelvic  peritonitis,  201 

Heat,  application  of,  in  pelvic  peritonitis, 
201 


INDEX 


221 


Hematosalpinx,   diflferentiated   from  pyo- 

salpinx,   145 
Hemorrhage,  of  fibrosis  uteri,  130 

—  uterine,  effect  on,  of  thrombokinase  and 

thrombolysin,  129 

Hernia,  pudendal,  differentiated  from  ab- 
scess of  Bartholin's  gland,  4 

Hunner  and  Russell,  linear  cauterization 
method  of,   for  endocervicitis,  22 

Hydrosalpinx,  definition  of,  138 

—  differentiated  from  pyosalpinx,  145 

—  pathology  of,  139 

—  prognosis  of,  146 
Hyperplastic  ovaritis,    191 
Hypertrophy,  of  the  ovary,  193 

—  uterine,  gross  pathology  of.     See  also 

Metritis,  Chronic 
Hysterectomy,      for     chronic     salpingitis. 

points  conducing  to  best  success,  172 
technic  of,  173 

—  in  treatment  of  fibrosis  uteri  and  me- 

tritis,  chronic,   134 

—  vaginal,    with    double    salpingo-oopho- 
rectomy,  for  chronic  salpingitis,  168 

Hysterosalpingostomy,  for  chronic  salpin^ 
gitis,  168  ^° 

Immunity,  individual,  to  gonorrheal  in- 
fection, variability  of,  57 

—  nature's    establishment    of,    in    gonor- 

rheal infection,  56 

Incision  of  Bartholin's  gland,  for  abscess, 
5 

Inclusion  cysts  of  lower  vaginal  wall,  dif- 
ferentiated from  abscess  of  Bartho- 
lin's gland,  4 

Infections,  of  Bartholin's  ducts  and  gland 
(gonorrheal),  abscess  formation  in,  3 

differentiated  from  other  condi- 
tions, 3,  4 

treatment  of,  4  " 

persistent  nature  of,  3 

symptoms  and  physical  signs  of,  3 

—  gonorrheal,  most  common  points  of,  1 
of  Skene's  glands,  1 

—  postabortal,  prognosis  of,  106 

—  postpartum  septic,  prognosis  of,  105 

—  puerperal,  prognosis  of,  105 
treatment  of,   107 

—  of  Skene's  glands   (gonorrheal),  diag- 

nosis of,  2 

persistent  nature  of,  1 

treatment  of,  2 

—  of  the  veins,  puerperal  pyemia,  97 

clinical  characteristics  of,  97 

complications  of,  98 

due,  in  nearly  all  cases  to  intra- 
uterine manipulations,  97 
frequency  of,  97 


Infections,  of  the  veins,  puerperal  pyemia, 

history  of,  97,  98 

physical   signs   of,  98 

prognosis  of,  98 

thrombophlebitis  of  the   femoral  or 

saphenous  vein,  characteristics  of,  95 

clinical    causes    of,   95 

onset  of,  95 

symptoms  of,  96 

treatment    of,    98 

thrombophlebitis  of  the  pelvic  veins, 

treatment  of,  99 
thrombophlebitis    of    the   pelvic   and 

crural  veins,  96 

types  of,  puerperal  pyemia,  97 

thrombophlebitis    of    the    femoral 

or  saphenous  vein,  95 

—  vulvovaginal,   prognosis  of,   106 
Inflammation,     of    the     Fallopian    tubes, 

gonorrheal,    46 

—  of     intracervical     mucous     membrane. 

See  Endocervicitis 

—  of  the  vagina.     See  Vaginitis 

—  of  the  vulva.     See  Vulvitis 
Injection,  method  of,  in  gonorrheal  ure- 
thritis, 57 

Injection,  in  treatment  of  gonorrheal  in- 
fection of  Skene's  glands,  2 

Intestinal  peristalsis,  arrest  of,  in  pelvic 
peritonitis,   200 

Intestinal  tympany,  due  to  salpingitis, 
141 

Intra-uterine   douches,   objections  to.    110 

Intra-uterine  manipulations,  puerperal  py- 
emia due  to,  97 

Involution  of  the  uterus,  diminution  in 
volume  of  muscle  fibers  and  connec- 
tive tissue  during,  125 

—  effect  of  sepsis  on,  124 

—  fatty  degeneration  in  muscle  fibers  dur- 

ing, 125,  126 

—  fibrosis  uteri,  due  to,  123 

—  normal  process  of,  124 

—  normal   process   of,  conditions  hinder- 

ing, 127 

Goodall  on,   125' 

Irrigations,  vulvar,  in  treatment  of  gon- 
orrheal infection,  55 

of  gonorrheal   vaginitis,   58 

"Isthmic  node,"  in  hydrosalpinx,   139 


Labor,  changes  in  uterus  after,  125 

—  prophylactic    measures    against     puer- 

peral infection  in,  107,  108 

—  septic    infections    in    connection    with. 

characteristic  features  of,  66 
Laparotomy,    for    tubercular    peritonitis, 
214 


222 


INDEX 


Lavage,  in  pelvic  peritonitis,  200 
Leukocytic  resistance,  in  thrombophlebitis, 

lOO' 
Leukocytosis,  infection  arrested  by,  120 

—  local  and  general,  produced  by  staphy- 

lococcus infection,  64 
Leukorrhea,  cervical,  as  symptom  of  en- 
docervicitis,  17,  18 

—  of    endocervicitis,    differentiated    from 

the  discharge  of  cervical  cancer,  19 

—  in  fibrosis  uteri,  130 

— most  constant  symptom  of  chronic  gon- 
orrheal endometritis,  45 

—  mucopurulent,  in  salpingitis,  140,  149 

—  radium  in  treatment  of,  24 

Lochia,     bloody,     excessive,     fetid     and 
frothy,  79 

—  serous,   flesh   colored   or   seropurulent, 

81 


Maculae  gonorrheae  of  Sanger,  54 
Menorrhagia,  due  to   salpingitis,   172 
Menstrual  disturbances,  in  chronic  gonor- 
rheal endometritis,  45 

—  in  chronic  pelvic  inflammation,  52 

—  in  salpingitis,  141 

Menstrual  function,  preservation  of,  in 
choice  of  operative  procedure  for  sal- 
pingitis, 166 

—  increased   susceptibility  during,  of  en- 

dometrium and  tubes  to  extension  of 
gonorrheal     infection     from     cervix, 
56 
Metritis,  chronic,  allied  with  fibrosis  uteri, 
123 

—  changes  due  to  subinvolution,  128 

—  differential  diagnosis  of,  130 

—  etiology  of,  129 

—  gross  pathology  of,  124 

—  prognosis  of,  131 

—  signs  and  symptoms  of,  130 

—  treatment  of,  drugs,    132 
galvanism,  132 

hot  douches,  132 

hysterectomy,  134 

indications    for,    131 

rest,  132 

surgical,  curettage,  133 

radium,  133 

vaginal  tamponade  or  pack,  132 

—  gonorrheal,  pathology  and  histology  of, 

45 
Metrorrhagia,     accompanying    endocervi- 
citis, 18 

—  due  to  salpingitis,  172 

Mucosa,  cervical,  susceptibility  of,  to  in- 
fection, 15 

—  corporeal,  immunity  of,  to  infection,  15 


Mucosa,  structure  and  function  of  cervi- 
cal as  opposed  to  corporeal  mucosa,  15 

Muscular  rigidity,  in  pelvic  peritonitis, 
196 

Nausea  and  vomiting,  in  pelvic  peritonitis, 
196 

treatment  of,  200 

Nephrolithiasis,  differentiated  from  sal- 
pingitis, 144 

Ointment,  for  relief  of  pruritis,  formula 

for,  9 
Oophoritis.     See  Ovaritis 
Ovarian  tumors,  differentiated  from  pyo- 

salpinx,  144 
Ovary,  histologic  structure  of,  187 

—  preservation  of,  in  choice  of  operative 

procedure  for  salpingitis,  168 

—  resection  of,  to  be  discouraged,  192 
Ovaritis,  atrophic,   190 

—  chronic,   189 

etiology  of,  190 

physical  signs  of,  188 

prognosis   of,   191 

symptoms  of,  188 

treatment  of,  189 

—  cystic,  190 

—  definition  of,  190 

—  etiology  of,  190 

in  chronic  form,  190 

—  history  of,  190 

—  hyperplastic,  190 

—  hypertrophic,  192 

—  mode  of  invasion  of,  190 

—  pathology  of,  190 

—  symptoms  and  signs  of,  190,  191 

—  treatment  of,  191 

Pack,    vaginal,    in    chronic    metritis    and 

fibrosis  uteri,  132 
Pain,  of  fibrosis  uteri,  130 

—  pelvic,   as   a   symptom   of   pelvic    peri- 

tonitis, 195 
Paracentesis,   in   treatment  of   tubercular 

peritonitis,  212 
Parametric    abscess,    differentiated    from 

pyosalpinx,   145 
Parametritis,   associated    with   salpingitis, 

148 

—  lateral,  as  a  result  of  attempts  at  dig- 

ital or  instrumental  evacuation  of  the 
uterus,  80 

—  perimetritis  due  to,  88 

—  treatment  of,   113 

—  See  also  Cellulitis,  pelvic 
Parametrium,    seat   of    streptococcic   sal- 
pingitis, 148 


INDEX 


223 


Pelvic  abscess,  due  to  pelvic  peritonitis, 

physical   signs  of,  203 
treatment  of,  203 

—  due  to  salpingitis,   140 

symptoms  of,   152 

treatment  of,  152 

Pelvic  cellulitis.     See  Cellulitis,  pelvic 

Pelvic  infections,  bacteriology  of,  bacillus 
aerogenes  capsulatus,  64 

bacillus  coli,  64 

bacteria  common  to  flora  of  vulva, 

65 

classes  of  infective  bacteria,  62 

gas  bacillus  infection  during  preg- 
nancy, 65 

gonococcus  of  Neisser,  62 

—  — leukocytosis,  local  and  general,  pro- 

duced by  staphylococcus,  64 

mode  of  infection,  65 

non-pathogenic    bacteria    normal    to 

vulva,  vagina  and  cervix,  65 

rendered  pathogenic,  66 

staphylococcus,  64 

— ■  —  streptococcus  pyogenes,  63 

—  catharsis  to  be  avoided  in,  114 

—  causation  of.     See  Bacteriology  of' 

—  general   considerations,   62 

—  leukocytosis,    local    and    general,    pro- 

duced by  staphylococcus  infection,  64 

—  mode  of  occurrence  of,  62 

—  puerperal.    See  Puerperal  Infections 

—  susceptibility   to,    during   different    pe- 

riods of  life,  62 
Pelvic    inflammation,    acute,    gonorrheal, 

prognosis  of,  52 
— ■  —  symptoms  of,  51 

—  chronic,  acute  exacerbations  of,  52 
cervical  infection  in,  52 

history  of,  52 

menstrual  disturbances  in,  52 

symptoms   of,   52,  53 

—  groups  of,  and  their  incidence  in  differ- 

ent countries,  50 

—  importance  of  etiology  of  each  case  for 

both  prognosis  and  treatment,  50 

—  infections.     See   Infections 
Pelvic  peritonitis,  causes  of,   193 

—  clinical  picture  of,   116 

—  diagnosis  of,  197 

—  exudate  of,  197 

—  gonococcic,   193 
prognosis  of,  197 

—  physical  signs  of,  197 

—  prognosis  of,  197 

gonococcic  form,  198 

puerperal,  198 

—  puerperal,  prognosis  of,   198 

uterus  enlarged  and  well  out  of  true 

pelvis,  199 


Pelvic  peritonitis,  pyogenic,   194 

—  resulting    in    pelvic    abscess,     physical 

signs  of,  203 
treatment  of,  203 

—  spreading,   symptoms   of,  202 
treatment  of,  drainage,  202 

—  spreading     postabortal,     treatment     of, 

203 

—  symptoms   of,  abdominal   tension,    196 
chill,  195 

constipation,   195 

muscular  rigidity,  195 

nausea  and  vomiting,  195 

pain,  195 

pulse,  195 

tympanites,  195 

—  symptoms  of  spreading  infection,  202 

—  treatment  of,  115 

application  of  heat,  201 

application  of  cold,  202 

—  arrest  of  intestinal  peristalsis,  200 

—  drainage,  202 
Harris  drip,  201 

as  indicated  by  cause  and  type  of  in- 
fection,  198 

lavage,  200 

localization  of  inflammatory  re- 
action of  the  peritoneum,  199 

for  nausea  and  vomiting,  200 

opiates  for  relief  of  pain,  200 

palliative,  summarization  of,  202 

posture,  199 

for  relief  of  pain,  application  of  heat 

or  cold,  201 

opiates,  200 

rest,  199 

for  resulting  pelvic  abscess,  203 

in  spreading  infection,  202 

in  spreading  postabortal  cases,  203 

for  tympany,  201 

Perimetritis,  due  to  parametritis,  88 

—  treatment  of,  115 

Perisalpingitis,  associated  with  tubercu- 
lous peritonitis,  209 

Peristalsis,  inhibition  of,  in  salpingitis, 
150 

—  intestinal,   arrest   of,    in   pelvic   perito- 

nitis, 200 
Peritoneal  infections,  treatment  of,  115 
Peritoneum,  involvement  of,  in  inflamma- 
tions of  genital  organs,  193 
Peritonitis,    definition   of,    193 

—  differentiated  from  cellulitis,  93 

—  general,  treatment   of,    118 

—  pelvic.     See  Pelvic  Peritonitis 

—  tuberculous.     See  Tuberculous  Perito- 

nitis 
Phlebitis,  pelvic,  attended  always  by  cel- 
lulitis, 97 


224 


INDEX 


Phlegmasia  alba  dolens,  complicating  pel- 
vic cellulitis,  90 

Placenta,  spontaneous  separation  and  ex- 
pulsion of,  108 

Placental  forceps,  danger  of.  111 

Postabortal  infection,  primary  inflamma- 
tory lesion  in,  11 

—  prognosis   of,    106 

Posterior  colpotomy,  in  treatment  of  pus 
tubes,  indications   for,   153 

technic  of,  154 

Postpartum  septic  infections,  prognosis 
of,  105 

Postpartum  uterus,  physiological  process 
within.  75 

Postures,  Fowler  elevated  trunk,  for  uter- 
ine drainage,  109 

Pregnancy,  changes  in  uterus  during,  125 

—  gas  bacillus  infection  during,  65 

—  protecting  organisms  against  infection 

during,  65 

—  tubal.     See  Tubal  Pregnancy 
Pruritis,    of    diabetic    vulvitis,    treatment 

of,  9 

—  treatment  of,  in  diabetic  vulvitis,  9 
Pudendal  hernia,  differentiated  from  ab- 
scess of  Bartholin's  gland,  4 

Puerperal  endometritis,  cause  of,  74,  75 

—  coccal,  80 

—  forms  of,  according  to  Bumm,  72 

—  frequency  of,  74 

—  limitation  of  infection  to  placental  site, 

IZ 

—  pathology  of,  71 

—  as    primary    lesion    in    puerperal    and 

postabortal  infection,  11 

—  putrid  or   saprophytic,   78 

cause  and  process  of,  79 

prognosis   of,   79 

symptoms  of,  79 

—  symptoms  of,  81 

Puerperal  endometrium,  local  changes  in, 
70 

—  nature  of,  70 

—  in  putrid   form,  description  of,  12> 
Puerperal  fever,  cause  of,  74,  75 

—  frequency  of,   74 

—  due  to  putrid  or  saprophytic  endome- 

tritis, 79 

—  mortality   from,   74 

Puerperal  infections,  avenues  of  entrance 
for  bacteria,  67 

—  bacteria  of  the  genital  region,  68 

—  bacteriemia,    102 

—  beginning  of,  67 

—  birth  traumatisms,  67 

—  causation   of,  inoculation   of   puerperal 

wound  with  pathogenic  bacteria,   107 
— cellulitis,  bacteriemia  due  to,  89 


Puerperal  infections,  cellulitis,  chronic, 
90 

complicated  by  femoral  thrombosis, 

90 

by  phlegmasia  alba  dolens,  90 

definition  of,  81 

effect  of,  on  blood  supply,  88 

exudates  in  the  cellular  tissue,  86 

pathology  of,  85 

pelvic,  avenues  of  entrance,  85 

due  to  infections  from  trauma- 
tisms of  the  vagina  and  cervix, 
82 

-etiology  of,  84 

factors  affecting  severity  of,  84 

increase  in  amount  of  pelvic  cel- 
lular tissue  during  pregnancy,  83 

location  of  cellular  tissue  in- 
volved, 82,  83 

-location   of  cellular  tissue  in  the 

pelvis,  81 

— rare  after  abortion,  85 

symptoms  of,  90 

—  classification  of,  69 

blood  states,  69 

focal  infections,  69 

—  endometritis,  cause  of,  74,  75 
coccal,  80 

forms  of,  according  to  Bumm,  12 

frequency  of,  74 

pathology  of,  71 

as  primary  lesion  in  most  cases,  11 

putrid  or  saprophytic,  78 

cause  and  process  of,  79 

— prognosis  of,  79 

symptoms  of,  79 

symptoms  of,  81 

—  endometrium,    puerperal,    consideration 

of,  70 

—  focal,  primary,  69 

puerperal   endometritis,  71 

puerperal  ulcers,  69 

—  gas  bacillus,  121 

—  infective     bacteria     in     postabortal    or 

postpartum  uterus.  Id 

—  manipulation,    manual    and    instrumen- 

tal,  infective   processes   extended   by, 
119 

—  pathology  of,  blood  states,  69 

classification  of  infections,  69 

■ primary  focal  infection,  69 

—  parametritis,  lateral,  as  a  sequel  of  at- 

tempts    at     digital     or     instrumental 
evacuation,  80 

—  primary  inflammatory  lesion,  11 

—  prognosis  of,  105 

—  prophylactic  treatment  of,  107 

prevention   of   perineal   and   vaginal 

tears,  108 


INDEX 


225 


Puerperal  infections,  prophylactic  treat- 
ment of,  rules  governing  vaginal  ex- 
aminations, 108 

spontaneous  separation  and  expul- 
sion of  the  placenta,  108 

• — •- — underlying   principles   of.    107 

—  puerperal  fever,  cause  of,  74,  75 

—  —frequency  of,   74 

—  —  mortality  from,  75 

—  rupture  of   the  vagina,  75 

—  septic  wounds  of  the  vagina,  after  in- 

strumental delivery,  75 

—  treatment    of,    107 

curative,    avoidance   of    catharsis   in 

pelvic  infections,  114 

bacteriemia,  119 

basis  of,  108 

gas   bacillus  infection,    122 

general,  113 

in  general  peritonitis,   118 

hygienic,  113 

local  measures,  curettage,   111 

intra-uterine  douches,  110 

placental   forceps,  use  of,   111 

swabbing  out  the  uterus,  110 

in  pelvic  peritonitis,  115 

in  perimetritis,  115 

in  peritoneal  cases,   115 

uterine  drainage,  109 

in  parametric  invasions,  113 

prophylactic,    107 

underlying  principles  in  the  con- 
duct of  an  aseptic  delivery,   107 

in    putrid     endometritis     with    poor 

drainage,  111 

uterine  manipulation  absolutely  con- 
tra-indicated, 110,  111 

—  ulcers,  69 

—  uterine,  coccal  endometritis,  80 
factors   favoring,  11 

introduced   from  the  outside,  78 

physiological      process     within     the 

uterus    after    evacuation   of    its    con- 
tents, 75 
prevention  of,  78 

—  uterus   normally   protected    from   inva- 

sion  by   infective   bacteria    from    the 
interior,  both  during  and  after  labor, 
76,  78 
— vaginitis,  superficial,  with  purulent  dis- 
charge, 75 

—  venous.     See  Infections  of  the  Veins 

—  vulvar,  appearance  of,  75 
Puerperal  peritonitis,  prognosis  of,  199 
Puerperal  pyemia,  clinical  characteristics 

of,  97 

—  complications  of,  98 

—  due,  in  nearly  all  cases,  to  intra-uterine 

manipulations,  97 


Puerperal  pyemia,   frequency  of,  97 

—  history   of,   97,   98 

—  physical  signs  of,  98 

—  prognosis  of,  98 
Puerperal  ulcers,  69 

Puerperium,  effect  of  sepsis  on  involution, 
124 

—  gas  bacillus   infection  during,  65 

—  protecting  organisms   against  infection 

during,  65 

—  septic    infections    in    connection    with 

characteristic  features  of,  66 
Pulse    acceleration,    in    pelvic    peritonitis, 

197 
Pus  tubes,   139,  148 

—  treatment  of,  153 
Pyemia,  prognosis  of,  107 

—  puerperal.     See  Puerperal  Pyemia 
Pyosalpinx,  139 

—  as  termination  of  gonorrheal  salpingi- 

tis, 47 

—  differentiated    from    appendicular    ab- 

scess, 146 

from  fecal  tumors,  144 

from  hematosalpinx,  145 

from  hydrosalpinx,   145 

from  ovarian  tumors,  144 

from  parametric  abscess,  145 

tubal  pregnancy,  144 

—  physical    signs   of,    144 

—  prognosis  of,  146 

—  ruptured,  prognosis  of,  147 

Radium,  in  treatment  of  endocervicitis,  24 

of  fibrosis  uteri  and  chronic  metritis, 

133 

of  leukorrhea,  24 

Rectal  examinations,  prohibited  in  gonor- 
rheal infection,  56 

Resection  of  ovarv,  to  be  discouraged, 
193 

—  partial,     of     Fallopian     tubes,     clinical 

value  of,  as  a  conservative  operation, 
160 
Retention  cyst  of  vulvovaginal  gland,  dif- 
ferentiated  from  abscess  of   Bartho- 
lin's gland,  4 

Sactosalpinx,  formation  of,  138 
Salpingectomy,  technic  of,  170 
Salpingitis,   acute.    136 

adhesions  formed  in,  136.  138.  139 

clinical  phenomena  of.  140 

diflferential  diagnosis  of  from  ap- 
pendicitis, 142 

from     gall-bladder     inflammation, 

143 

from  nephrolithiasis,  144 

from  ureterolithiasis,  144 


226 


INDEX 


Salpingitis,  acute,  displacement  of  tube  in, 

137 

history,   significance  of,    140,   143 

pathology  of,   136 

-physical  signs  of,   142 

pus  in,  nature  of,  139,  148 

symptoms  of,   140 

terminations  of,  hydrosalpinx,  138 

pelvic  abscess,  140 

pyosalpinx,  139 

regeneration  of  tube,  137 

resolution,    137 

rupture  into  the  peritoneal  cavity, 

139 

sactosalpinx,  138 

secondary    infection    by    bacillus 

coli,   139 
subacute  or  chronic  inflammation, 

138 
treatment  of,  150 

—  bacteriology  of,  135,  136,  148 

—  causes  of,  135 

before  puberty,  136 

—  characteristic  lesions  of,  148 

—  chronic,    involvement    of    uterus    and 

ovaries  in  inflammatory  process,  172 

menorrhagia  or  metrorrhagia  due  to, 

170 

symptomatic  cure  of,  142,  148 

symptoms  of,  141 

as  termination  of  acute,  138 

treatment  of,   operative,   Bell-Beutt- 

ner  procedure,   172 

considering     metritic     changes, 

166 

hysterectomy,  technic  of,  171 

hysterosalpingostomy,    166 

to  preserve  ovulation  and  men- 
strual function  in  young  women,  166 

radical,  171 

salpingectomy,    170 

salpingostomy,    168 

vaginal  hysterectomy,  with  dou- 
ble salpingo-oophorectomy,  166 

palliative,  157 

—  definition   of,   135 

—  due  to  mixed   infections,   136 
termination  of,  138 

—  gonorrh  ;al,     definite     microscopic     ap- 

pearances in,  47 

differentiated  from  tubercular  peri- 
tonitis of  indurative  form,  210 

histology  of,  47 

prognosis    of,    147 

symptomatology     of,     inclusive     of 

symptoms  of  peritoneal  reaction,  51 

termination   of,   as  pyosalpinx,   47 

—  hydrosalpinx,  definition  of,  138 
differentiated  from  pyosalpinx,  145 


Salpingitis,    hydrosalpinx,    pathology    of, 

139 
prognosis  of,  146 

—  infective   agents  in,   135,   136.  148 

—  latent,   due   to   streptococcus,   148 
sterility  due  to,   149 

tuberculous,   149 

—  metritic  changes  in,  163,  164 

—  mucopurulent    leukorrhea    in,    140,    149 

—  operative   prognosis   of,    in   septic   and 

gonorrheal  cases,  149 

—  parametritis  associated  with,  148 
— ^  pelvic  abscess  due  to,  140 

symptoms  of,  152 

treatment  of,  153 

—  prognosis  of,  146 

operative,   in   septic  and  gonorrheal 

cases,   149 

in  ruptured  pyosalpinx,  147 

in  streptococcic  infections,  compli- 
cated by  parametria!  exudate,  148 

in  tuberculous  infection,  149 

—  purulent,  prognosis  of,  147 

—  pus  accumulations  in,  139,  148 

—  pyosalpinx,  139 

— ' — differential  diagnosis  of,  144 

physical  signs  of,  144 

prognosis  of,  146 

rupture  of,   147 

—  routes  of  infection,  135,  148 

—  sterility  due  to,  149 

—  streptococcic,   148 

—  subacute,  symptoms  of,  141 
as  termination  of  acute,  138 

—  tendency  of,  to  spread  to  peritoneum, 

150 

—  treatment  of,  in  acute  cases,  150 
Harris  drip,  156 

management     without     operation, 

150 

operative,   153-157 

in    chronic    cases,    operative,     Bell- 

Beuttner  procedure,  172 

considering     metritic     changes, 

166 

•  —  hysterectomy,    technic,    171 

hysterosalpingostomy,    166 

to  preserve  ovulation  and  men- 
strual function  in  young  women,  166 

radical,    171 

salpingectomy,  170 

salpingostomy,   168 

vaginal  hysterectomy  with  dou- 
ble  salpingo-oophorectomy,    166 

palliative,  157 

operative,  abdominal  route,  contra- 
indications to,  156 

Bell-Beuttner   procedure,    162 

considering  metritic  changes,  166 


INDEX 


227 


Salpingitis,  treatment  of,  operative,  hys- 
terectomy, technic,  171 

hysterosalpingostomy,   166 

indications   for,   153,   157 

posterior    colpotomy,    indications 

for,  153 

— technic  of,   154 

to  preserve  ovulation  and  men- 
strual function  in  young  wom.en,  166 

radical,  171 

salpingectomy,  technic  of,   170 

salpingostomy,  indications  for,  168 

technic  of,  169 

vaginal  hysterectomy  -whh  double 

salpingo-oophorectomy,   166 

for  pelvic  abscess,  152 

—  tubercular,  differentiated  from  tubercu- 

lar peritonitis,  211 

diagnosis  of,  142 

prognosis  of,  149 

Salpingostomy,  indications  for,  168 

—  technic  of,  169 
Senile  vaginitis,  12 

—  symptoms  of,  12 

—  treatment  of,  13 

Sepsis,  as  cause  of  salpingitis,  135 
Septic  infections,  in  connection  vj'xth   la- 
bor,    abortion     or     the     puerperium, 
characteristic  features  of,  66 
Skene's  glands,  anatomy  of,  1 

—  gonorrheal  infection  of,  diagnosis  of,  2 
persistent  nature  of,  1 

treatment  of,  2 

latent,  reinfection  of  urethra  from, 

58 

Skin  protective,  for  relief  of  pruritis,  for- 
mula of,  9 

Staphylococcus,  forms  of,  64 

—  history  of,  64 

—  leukocytic  reaction  of,  64 

—  pus-producing  nature  of,  64 
Sterility,  due  to  endocervicitis,  18 

—  due  to  gonorrhea,  35,  36 

—  due  to  salpingitis,  149 
Streptococcus   pyogenes,   as   chief   infect- 
ing agent  of  cellular  tissue,  84 

—  entry  and  route  of,  63 

—  exudate  of,  6Z 

—  forms  of,  63 

—  history  of,  63 

—  virulence  of,  62) 
Streptococcic  salpingitis,  148 
Sturmdorf's    technic,    for    surgical    treat- 
ment of  chronic  endocervicitis,  26 

Subinvolution  of  the  uterus,  changes  due 
to,  128 

—  gross  pathology  of.     See  also  Metritis, 

chronic 

—  prognosis  of,  131 


Subinvolution  of  the  uterus,  treatment  of. 
See  Metritis,  chronic. 

Suppositories,  prohibited  in  gonorrheal  in- 
fection, 56 

Suppuration  of  pelvic  exudates,  89 

Syphilitic  ulceration  of  the  cervix,  19 

Tamponade,  vaginal,  in  fibrosis  uteri  and 

chronic  metritis,  132 
"Thrombokinase,"  function  of,  129 
"Thrombolysin,"   function  of,   129 
Thrombophlebitis,  as  a  conservative  proc- 
ess of  Nature,  99,  100 

—  of  the  femoral  or  saphenous  vein,  char- 

acteristics of,  95 

clinical  causes  of,  95 

focus  of,  96 

symptoms  of,  96 

treatment  of,  98 

—  leukocytic   resistance   in,    100 

—  of  the  pelvic  veins,  treatment  of,  99 

blood  transfusions,  100 

expectant,  99,  100 

radical,  101 

—  of  the  pelvic  and  crural  veins,  96 

—  prognosis  of,  106 

Thrombosis,  femoral,  complicating  pelvic 

cellulitis,   90 

prognosis  of,  106 

differentiated  from  cellulitis,  90 

Toxinemia,   due  to   endometritis   putrida, 

79 
Transfusion,  in  infection,  120 
of  citrated  blood,  121 

—  repeated,    small,    in    thrombophlebitis, 

100 

Trauma,  as  cause  of  endocervicitis,  15 

Traumatisms  of  the  birth  canal,  as  ave- 
nues of  entrance  for  bacteria,  67 

Tubal  pregnancy,  differentiated  from  pyo- 
salpinx,    144 

Tubercle,  description  of,  207 

Tuberculin,  in  treatment  of  tubercular 
peritonitis,  213 

Tuberculosis,  of  the  cervix,  endocervicitis 
differentiated  from,   19 

hyperplastic,  19 

miliary,  19 

primary,  19 

ulcerative,  19 

—  of  the  Fallopian  tubes,  diagnosis  of,  46 

secondary  nature  of,  46 

Tuberculous      endosalpingitis,     associated 

with  tuberculous  peritonitis,  209 
Tuberculous  lesions,  tendency  to  undergo 

caseation,  206 
Tuberculous   peritonitis,  acute,  symptoms 

of,  207 

—  adhesive,  symptoms  of,  208 


228 


INDEX 


Tuberculous  peritonitis,  associated  with 
tuberculous  endosalpingitis  and  peri- 
salpingitis, 209 

—  caseous,  symptoms  of,  209 

—  characteristic  of,  in  early  stages,  207 

—  chronic,   symptoms  of,  208 

—  cyst  formation  in,  208 

differential  diagnosis  of,  209 

—  definition  of,  204 

—  description  of  the  tubercle,  206 

—  diagnosis  of,  210 

clinical   test  of   Judd   of   the    Mayo 

Clinic,  211 

—  differential  diagnosis  of,  in  cyst  forma- 

.tion,  208 

of  indurative  type  from  gonorrheal 

salpingitis,  210 
from  tubercular  salpingitis,  210 

—  fibrinous,  symptoms  of,  208 

—  hyperacute,  appearance  of  peritoneum, 

206 

—  incidence  of,  with  tuberculosis  in  other 

parts  of  body,  205 

—  indurative,   differentiated   from  gonor- 

rheal salpingitis,  210 

—  occurrence  of,  age,  204 
heredity,  204 

sex,  204 

—  primary,  205 

—  process  of  healing,  207 

—  prognosis  of,  211 

—  routes  of  extension  from  primary  fo- 

cus, 205 

by  the  blood  stream,  206 

by  contiguity,  206 

by  continuity,  206 

—  secondary,  206 

—  serous,    without    adhesions,    symptoms 

of,  208 

—  subperitoneal,  210 

symptoms  of,  208 

in  acute  type,  207 

in  adhesive  type,  208 

in  caseous  type,  209 

in  chronic  type,  208 

in  fibrinous  type,  208 

in   serous   cases,   without  adhesions, 

208 

—  tendency  to  undergo  caseation,  206 

—  treatment  of,  212 
climate,  212 

operative,  laparotomy,  213 

paracentesis,    212 

tuberculin,  212 

X-ray  therapy,  212 

Tuberculous  salpingitis,  diagnosis  of,  142 

—  differentiated    from    tubercular    perito- 

nitis,  210 

—  prognosis  of,  149 


Tumors,  fecal,  differentiated  from  pyo- 
salpinx,  144 

—  vulvar,   differentiated   from  abscess  of 

Bartholin's  gland,  4 
Tympanites,    in   pelvic  peritonitis,    196 
Tympany,  intestinal,  as  a  symptom  of  sal- 
pingitis, 141 

Ulcers,  puerperal,  69 

Ureterolithiasis,  differentiated  from  sal- 
pingitis, 144 

Urethra,  examination  of,  for  gonorrheal 
infection,  54 

Urethritis,  associated  with  gonorrheal 
vulvitis,  38 

—  gonorrheal,       abscess      formation      in 

Skene's  glands  or  any  of  the  mucous 
glands  of  the  urethra,  38 

process  of,  38 

treatment  of,  57 

Uterine  douches,  objections  to,  110 

Uterine  drainage,  chief  contributing  fac- 
tor in  normal  uterine  reaction  against 
bacterial  invasion,  109 

—  Fowler  elevated  trunk  posture,  109 

—  postural,  109 

—  by  securing  proper  uterine  retraction, 

109 

Uterine  hypertrophy,  gross  pathology  of. 
See  also  Metritis,  chronic 

Uterine  infection,  puerperal,  factors  fa- 
voring, n 

prevention    of,    78 

Uterine  secretions,  bactericidal  action  of, 
68 

Uterus,  capable  of  emptying  itself,  when 
well  contracted  and  in  normal  ante- 
version,  78 

—  changes  in,  after  labor,  125 
during  pregnancy,  125 

—  enlargement  of,  due  to  salpingitis,   166 

—  evacuation  of,  digital  or  instrumental, 

danger  of,  78,  80 
normal,  78 

—  infection  of,  fibrosis  uteri  due  to,   123 

—  involution  of.     See  Involution 

—  physiological      process      within,      after 

evacuation  of  its  contents  in  labor,  75 

—  postabortal     or     postpartum,     infective 

bacteria  in,  76 

—  self-protection  of,  against  invasion  by 

infective  bacteria  from  the  interior, 
both  during  and  after  labor,  76,  78 

—  self-sterilizing  powers  of,  68 

—  subinvolution   of,  changes   due   to,   128 
gross  pathology.     See  also  Metritis, 

chronic 

prognosis  of,  131 

treatment.    See  Metritis,  chronic 


INDEX 


229 


Uterus,  substances  affecting  hemorrhage, 
thrombokinase  and  tlirombolysin,   129 

—  swabbing  out  of,   objections   to,    110 

Vaccination,  diagnostic,  for  gonorrhea,  33 
Vagina,  rupture  of,  as  a  postpartum  se- 
quela, 75 

—  septic    wounds    of,    after    instrumental 

delivery,  75 
Vaginal  douches,  in  acute  gonorrheal  vag- 
initis, 58 

—  contra-indicated    in    gonorrheal    infec- 

tion, 56 

—  in  salpingitis,  151 

Vaginal  examinations,  indications  for, 
108 

—  number  of,  limited,   108 

—  puerperal  pyemia  due  to,  97 

—  removal  of  vulvar  hair  in  preparation 

for,  108 

Vaginal  hysterectomy,  with  double  sal- 
pingo-oophrectomy,  for  chronic  sal- 
pingitis, 164 

Vaginal  mucosa,  impaired  resistance  of, 
causes,  10 

—  resistant  nature   of,  to   bacterial  inva- 

sion, 10 
Vaginal     section,     for    peritonitis,    acute 
spreading,    of    pelvic    origin,    due    to 
abortion  or  tubal  leakage,  153 

—  in  treatment  of  pus  tubes,  indications 

for,  153 

technic  of,   154 

Vaginal    tamponade    or   pack,   in    fibrosis 

uteri  and  chronic  metritis,  132 
Vaginal  wall,  inclusion  cysts  of,  dififeren- 

tiated    from    abscess    of    Bartholin's 

gland,  4 
Vaginitis,  acute,  treatment  of,  13 

—  causes  of,  10 

—  chronic,    prognosis    of,    12 

—  clinical  varieties  of,  10 

—  definition  of,  9 

—  gonorrheal,  11 

acute,  treatment  of,  58 

avoidance  of  douches  or  irrigations 

during  acute  stage  of,  13 

diagnosis  of,  39 

presence  of  gonococcus  microscopi- 
cally demonstrated,  necessary  to  defi- 
nite diagnosis,  11 

process  of,  39 

prognosis  of,  12 

treatment   of,   13 

—  granular,    11 


Vaginitis,  granular,  symptoms   of,   12 

—  prognosis  of,  12 
• — senile,  12 

symptoms  of,   12 

treatment  of,  13 

—  simple,  symptoms  of,  11 

—  subacute,  treatment  of,  13 

—  superficial,  with  purulent  discharge,  as 

a  postpartum  sequela,  75 

—  usually  complicated  with  vulvitis,  10 
Varicosities,  pelvic,  due  to  cellulitis,  88 
Venous  infections.     See  Infections  of  the 

Veins 
Vomiting,  in  pelvic  peritonitis,  196 
Vulva,  bacteria  common  to  flora  of,  65 

—  inflammation  of.     See  Vulvitis 
Vulvar   infections,   puerperal,   appearance 

of,  75 

Vulvar  tumors,  differentiated  from  ab- 
scess of  Bartholin's  gland,  4 

Vulvitis,  acute  simple,  symptoms  of,  5 

treatment  of,  6 

—  chronic  simple,  symptoms  of,  6 
treatment  of,  6 

—  definition  of,  5 

—  diabetic,  cause  of,  9 

description  and  symptoms  of,  9 

treatment  of,  9 

—  follicular,  causes   and   symptoms  of,  8 
description  of,  8 

treatment  of,  8 

Bartholonitis  associated  with,  38 

occurrence  of,  7 

peculiarities  of,  37 

presence  of  gonococcus  microscopi- 
cally demonstrated,  necessary  to  defi- 
nite diagnosis,  7 

symptoms  of,  7 

treatment  of,  7 

urethritis  associated  with,  38 

—  simple,  causes  of,  5 
definition  of,  5 

symptoms  of,  6  ( 

treatment  of.  6 

Vulvovaginal  gland,  retention  cvst  of, 
differentiated  from  abscess  of  Bartho- 
lin's gland.  4 

Vulvovaginal  infections,  prognosis  of,  106 

Welch  bacillus.  See  Bacillus  aerogenes 
capsulatus 

X-ray  therapy,  in  treatment  of  tubercu- 
lar peritonitis,  213 

(2) 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RG  101  G997  1921  V.9C.1 

Pelvic  inflammation  in  women 


2002178761 


